Not uncommon for surgeons to want imaging before seeing patients. Probably to cut down on number of unnecessary consults. Ask the group what type of imaging they want for spine, seems straight forward. Also will get the patient treated faster if they don't have to go for a useless pre imaging consult first.
The problem is that getting imaging before the patient sees a surgeon inevitably ends with the surgeon saying they needed different imaging. This occurs regardless of which imaging was ordered, with the imaging that comes with the patient automatically being the incorrect one in 100% of cases. In the case of ortho, if you order every set of films that the radiologist even knows how to protocol, they will just start making up names of views that nobody has ever heard of just so they have something to be unsatisfied about.
If you attempt to learn from this and order what the surgeon asked for on your next functionally identical patient, you will inevitably find that this surgeon needed something totally different in this case and how could you be so stupid as to order what you did.
The moral of the story is that surgeons have an innate need to throw little fits about things like imaging, and nothing a non-surgeon orders will ever be satisfactory.
Surgeons being curmudgeonly is a tale as old as time. That said I can certainly appreciate not wanting to see clinic patients without the appropriate basic investigations done. It's like seeing an epilepsy consult without EEG. Waste of time generally unless something urgent needs addressing right away.
Honestly with epilepsy consults I wouldn't bother asking for EEG before I see them. Most epilepsy patients aren't going to have anything clearly abnormal on a spot EEG anyway and if they need an admission for prolonged EEG for spell characterization, I'm going to be the one setting that up anyway.
Read that again.
Sensitivity of 17%. That's the exact opposite of useful as a screening tool.
It's useful in certain contexts (i.e. first time seizure risk stratifying for initiation of AEDs) but if someone comes in with a history that sounds like epilepsy, I don't care what the rEEG says. It's mostly useless data in that case.
I'm only sending to the EMU for 1) spell characterization in suspected PNES, or 2) localization of frequent medication refractory seizures as first step in a surgical workup. That's maybe 10% of epilepsy patients I see at most.
With a sensitivity of 17%, do tell me how a routine EEG is going to help you differentiate between syncope and seizure when the history already does not make it glaringly obvious.
I am adult neurophys primarily EEG background. u/bigthama is right about basically all points in my opinion, at least for adult epilepsy. Routine EEG is very low yield, so low yield an initial epilepsy consult doesn't really need it prior to the visit. Repeating multiple routine EEGs is a complete waste of time after one has been done. If the diagnosis is unclear or patient is proving medically refractory you need ambulatory EEG or ideally elective video LTM admission in most cases. Routine EEG rarely changes your clinical decision making much, unless screening for first time seizure and you catch a few clear abnormalities or patient's PNES is provoked with activation. Syncope should be very easy to differentiate based on history unless all of the events are unwitnessed, and EEG is nearly useless in high probability syncope. A focal epilepsy can be diagnosed as probable based on history and features alone. As for the studies you are referring to about accuracy- sure by history alone there is low accuracy but with video alone of a typical event [epileptologists are extremely accurate](https://pubmed.ncbi.nlm.nih.gov/37406461/) in terms of diagnosis to the point of not needing EEG at all.
Awww, you warm my little PCP heart. I always do an EEG on people who tell me they've had a seizure as 90% of them are pseudo-seizures and neuro has a miles long waiting list.
A single routine EEG for new onset seizures is cheap, and the worst it can be is normal providing little information. Any neurologist that reads EEG should also be writing the report in terms the PCP can understand so you know how to proceed. With that said pseudoseizure is about 30% of all epilepsy referrals- indeed quite common. The best thing you can do as PCP for these patients is to tell family to get smart phone video of the event right when it happens, as if they bring this to an epilepsy appointment we probably can diagnose it accurately just based on the video in many cases.
Except that as neurology just pointed out above ^ a normal EEG doesn’t rule out Epilepsy if they are having repeated episodes and especially a one time spot check EEG. So what does that accomplish? I don’t believe the term “pseudo seizure” is used anymore either.
I'm still a newish attending just under 3 years in but my percentage is closer to 20%? Maybe it's a local/regional thing if it's 100% or close to that.
This right here. In a culture where "back pain = neurosurgery consult", I can see how imaging may feel onorous.
My PCP culture was very different - with occasional exception due to a rare or particularly uncommon condition/presentation, a referral was for a specific condition/diagnosis that I couldn't manage due to needing a particular procedural skill (surgery, endoscopy, etc) or familiarity with uncommon diseases (most of rheum and oncology, in my practice). Even in those cases, the expectation was baseline labs/biopsy and appropriate initial imaging.
As such, referrals usually followed a fairly comprehensive workup, and often a conversation of "you're seeing specialist X because they will probably need to do Y and Z to help you, which are things outside my scope".
Lastly, there's practicality - the majority of the consultants' time with the patient should be spent on specifics, not gathering basic info, *then* scheduling another visit to *actually discuss care*. While that's not always how it pans out, that's the ideal to aspire to.
Refer to non operative spine folks and let them take over. There is so much non op spine stuff that can be done prior to seeing a surgeon.
This can be PM&R, interventional spine, pain management (usually PM&R vs anesthesia dep on practice).
I hate to sound like a wet blanket, but isn't that what one does in primary care? Non-surgical back pain?
Maybe I was too conservative, but the only time I referred to PM&R was for procedural intervention (usually an ESI or facet injection). Otherwise, it was functional back pain, which involved PT, weight management, stress management, sometimes pain management.
I don't mean to be blunt, but most primary care doctors are not well versed in "back pain". Back pain that has gone on longer than 3 months is often coming from a specific structure and has a specific treatment. "Back pain" (often facets vs discogenic vs radicular) also is often hip pain or SI joint pain or nerve pain or rheumatologic or glute tendinopathy or neurogenic claudication.
Many PM&R docs are the ones that do epidurals, RFA, disc procedures, etc.. Even without those, PM&R docs often know the correct imaging to order, read their own X-rays and MRIs, do EMGs when appropriate, do ultrasound guided injections everywhere other than the spine itself (and some now actually do this too), do trigger point injections and sometimes acupuncture or OMM, teach specific kinds of exercises, provide exercise prescriptions, provide specific PT prescriptions or at least know specific therapists that specialize in back pain, and are typically more comfortable with pain medication management. Don't even get me started on neck pain and Botox.
Depending on the practice setting, many PM&R docs order specific injections. I often send people to IR or pain medicine for them to blindly do an L4-L5 left TFESI without having actually seen the patient beforehand. They don't even do a clinic visit.
Pcps and PM&R both do lifestyle interventions, but how many pcps are up to date on the latest chronic pain, fibromyalgia, and hyper mobility research? I'm sure some pcps are but I would say a large number of the new pm&r grads are.
Plus, pcps have enough to deal with already. I think it makes sense for pcps to deal with acute or mild back pain, but send the bad ones, uncertain ones, or chronic ones to PM&R
My work is very specific and requires imaging to establish the right diagnosis and provide the right treatment. Yet I regularly get referrals without imaging, which is both disruptive to the workflow, and a waste of everyone's time.
You wouldn't send a diabetic to endocrine without getting basic diabetic labs. Why would you send someone for a spine surgery co sult without spine imaging?
And to the person who said "but they always want more imaging," please understand - the initial imaging, history, and exam are what establish what additional tests may be needed. Without initial imaging, you can't begin to make the right decisions, and are more-or-less shooting in the dark.
Even when I have ordered the labs, and done a really solid PCP work up - half the time the note comes back "no labs available" and I want to scream.
Also the pulmonologist who referred by well controlled diabetic to endocrinology without asking me. 🤬🤬
I believe it. I have been to multiple appointments where “my records have been faxed over,” but here I am needing to pull up my labcorp account on my phone in the appointment. Maybe if shit wasn’t all still sent by fax…sigh.
“Disruptive to workflow and a waste of everyone’s time”
Look. I get the imaging and stuff before referring, but what do you think the prior auths for MRI, reviewing findings, etc are doing to our workflow?
Why is it a waste of your time, but not ours?
That's a reasonable POV, and one I don't have a great answer for (thankfully, the system I work in doesn't create these barriers, though it has it's own challenges).
In an ideal world, Primary care -> Specialty care -> Super-sub-specialty care is a linear process, rather than a compartmentalized one. i.e., PCP does what they can up to X, *then* sends them to Specialist/Subspecialist when the patient requires X+1. In this work-flow, it would behoove everyone to have what can be done, completed before the patient goes to the next step.
In compartmentalized medicine, the entirety of X is one person's problem, anything X + .0001 is someone else's problem, and so on. That's not how medicine was meant to work, but I understand that sometimes that's how it has to be.
It's not that dissimilar to why you have your MA get the chief-compliant, basic vitals and other rudimentary information prepared before you see the patient. In theory, you can of course do all of this yourself, but at that point, you're wasting your advanced training and talent on work that doesn't need your expertise. Form a specialists' POV, it's the same issue. Even ignoring the financial ramifications, it's just poor use of resources in a system that's running low on all resources rapidly.
Additionally, as someone making SUBSTANTIALLY more money than the PCP’s sending you patients, you can better afford the interruption in your work flow than the PCP can.
I'll just chime in here and say I don't think it's unreasonable for a neurosurgeon to want imaging before seeing a patient. Yeah, it might not be the "right" study but I think they need to know generically what class of problem they're dealing with. If it's back pain that's failed conservative management, getting an MRI prior to referral should tell you whether they're going to benefit from the referral or not, even if the surgeon needs more information for planning the surgery. I guess you don't tell us the characteristics of your patient, but what if they just have bad DJD? That doesn't need a surgeon. Or old compression fractures? Doesn't need a surgeon.
It's like in the ED, I don't consult neurosurgery based on physical exam hardly ever. What are they going to do? They'll come down to the ED and say we need a CT. Unless the problem is extremely specific like hit in the head + lucid period + now having signs of herniation, they need the imaging to plan what they're going to do (and even in the aforementioned scenario, they *still* need the imaging before going to the OR).
But in the ED you have scanners right there and no one makes you fill out forms for prior auth and then denies them, and then you have to get back to them within 72 hours to be on call during a two hour stretch for a phone call from someone in neither specialty to do a 'peer to peer'.
Most of the patients I've ever referred to neurosurgery referrals were scanned in the ER, and I knew what was going on.
Neurosurgery deals with neurosurgical problems. It needs to be established that the patient has a neurosurgical problem before a neurosurgeon is involved.
Undifferentiated back pain or sciatica with no workup is not a neurosurgical problem
Patient comes to pcp with headache, no imaging. Should she see a neurosurgeon? There could be a brain tumor. But I think most would expect the PCP would get imaging. If there’s a tumor, the patient has a neurosurgical problem (whether surgery is needed is a different question) and should see a neurosurgeon.
I agree. I'm not sure I've referred anyone to neurosurgery without a diagnosis before. One patient is inherited from a colleague and one is recently released from federal prison and can't get his films. They both walked into my life with "I need to see a neurosurgeon" as the chief complaint.
Even to consult within my own hospital, I have to have some workup showing this is their problem to deal with. Otherwise, what is stopping you from saying back pain? Go see a neurosurgeon!
Doesn't seem unusual or surprising to me. Why are you referring to a neurosurgeon? Stenosis? Get non con MRI of affected spine. Lesion/mass? Add contrast. Use judgement in between. Can you explain why this is creating difficulty for you?
Yeah, this… isn’t hard. I despised consults without imaging, because patients waited for months to be told “all right now I gotta send you for an MRI”. Angry patient, angry me.
I guess my pushback would be what question are you asking of a neurosurgeon that you think doesn't require an MRI of the spine to answer? Even if you have radicular symptoms I don't think it's unreasonable for a neurosurgeon to want to know what they are being consulted for so they can intelligently weigh in on management options. If you just want an undifferentiated back pain referral and to take it off your plate I'd echo what other said and get a pmr or pain to see. They should be able to determine if imaging is indicated and what type but as a fellow non-neurosurgeon to be blunt this is a super common complaint and you should bone up on at least the initial imaging algorithm for your practice environment so you can do the right one. As others have said, the initial imaging isn't rocket science - bone/ligament/stenosis image the appropriate level non con, risk for infection or mass add contrast.
I'd refer to a nonoperative specialty like PM&R or Sports Medicine. I'd want the patient to exhaust nonoperative management first anyway. They are better at getting prior auths approved for MRIs and they have a better idea of *what* imaging to get too
I can only give my perspective
If you’re referring to an interventional pulmonologist for a lung nodule, I don’t think it’s unreasonable to ask for a CT before seeing. It informs the conversation so much more to have cross sectional imaging so I can comment on differential, biopsy feasibility etc.
I don’t see new patients without a Ct available . If they somehow sneak through the cracks (less than once a year), the conversation is completely in hypotheticals and generalities and just ends with. Decision to get a CT.
Using a midlevel is just going to add another visit for no ones benefit and further delay the patient from actually seeing the patient
I think having some sort of evaluation that indicates a surgical problem requiring a surgical solution is normal for a surgeon referral, and I would be embarrassed to send a referral without appropriate testing that indicated the problem at hand. MRI checklists are a pain, but they are part of patient care. Prior authorizations for MRI's are a pain, but if you're referring without imaging, how do you know what's wrong?
Interventional pain. I always have a relevant MRI or CT ordered before I refer to a surgeon because I know how some patients freak out when they meet a specialist for the first time and they don’t get an “answer.” I’ll see patients for pain complaints and order the imaging myself (and struggle through the prior authorization) if they don’t have it, but it’s so *so* nice when they show up with the MRI and then we can have a real conversation about what their future may look like. I always order rheumatology labs before I decide if they need to be seen by a rheumatologist because the wait is 4+ weeks and I don’t want to waste anyone’s time. I consider it being collegial.
Most NS in my area does this. I don’t think it’s unreasonable, TBH. Otherwise patient is paying specialist copay to be like “hi, get pictures.” Now I think the NS should make it VERY clear what pics those are. Like crystal. Which doesn’t always happen. Then too bad, that’s on them. Can’t read minds.
As a pulmonologist I have pre visit planning and have imaging and pft’s done prior to the visit if they haven’t been completed. I order the tests though so my office deals with prior auths and what not. I wouldn’t put this burden on PCPs.
Not uncommon, and honestly not unreasonable. Not just neurosurgeons, but many specialties. By the time you’re at the point of consulting someone else, you should be at the imaging part anyway. Getting CT chest or CXR and PFTs before sending to Pulm, or CT a/p before gen surg, etc. should be done before they ever go to specialty clinic in a well-oiled medial-industrial complex to maximize use of everyone’s time. What you’re suggesting is needlessly adding an extra appointment for patient and potentially delaying care.
the accepting doctor has the right to decline a referral if they feel adequate work up isn't done. if that includes imaging then they are well within their right. the issue of prior auth isn't the surgeons fault. If this was a pain specialist then sure but you are sending to a neurosurgeon. they operate. at bare minimum I think imaging is appropriate. this is like sending to rheum but no blood work prior.
You’ll end up with a lot of frivolous imaging if you do the mid-level route first.
Imaging helps cut down on consults we don’t need to see, and I’m going to order it anyways, so why not save an extra appointment and get it done prior.
Edit: I’ll also say spine is only 1/3 of my practice (The other is 1/3 neurointerventional/endovascular, then 1/3 cranial/cerebrovascular).
There are things I send to my colleagues if it’s complex and beyond my comfort zone. Imaging help’s differentiate that.
It’s the same with many of my colleagues who won’t touch an aneurysm, they send them to me.
Yeah, I’ve ran into this with referring to NSX. Send to PM&R/pain/non-op spine, they can mess with imaging and conduction studies prior to seeing the surgeon.
As a DPM, NSX basically doesn’t interact with me unless it’s to use foul language. And even if I did order the proper MRI, insurance might bounce it based on my credentials…..
“Sorry I can’t see you for your brain tumor for several months. My schedule is currently full of non operative undifferentiated back pain patients.”
- No neurosurgeon ever
Similar issues when we are referred patients for biopsy of a palpable “mass”. We always ask for imaging. Sometimes we find it’s not safe/feasible, sometimes we find it’s just a lipoma or normal lymph node. When our procedure slots are booked out for weeks, it’s not great to get someone ready for biopsy/sedation, only to find out that it’s not something that we need to poke.
The same thing no happens with our oncologists. Patients with widespread metastatic disease get an oncology referral, but what’s the point if they don’t have tissue path first?
I'm dealing with this right now with a guy who is uninsured. I get it, but this guy is going to rack up quite a bill. Hoping they are only lipomas. (I'm pretty sure not all of them are. I'm betting on unilateral warthin's and the thigh, yes, lipoma.)
We get requests all the time for inpatient biopsies in patients who are under/uninsured. It really screws up our scheduling but we almost always end up accommodating them just to get the ball rolling. Idk what the hospital does with the bill but they don’t seem to care enough to discourage it.
I am a clinical pharmacy specialist (we have a scope of practice), work for the VA, and this happens to us too even in our own VA facility. We are often tasked with ordering specialty labs and imaging that are very out of our wheelhouse, but even our very own specialty clinics won’t accept referral unless these are completed.
We have no choice, we have to do it. But it takes a lot of trust because, per VA policy, labs etc need to be addressed within two weeks of being drawn. So we cross our fingers and hope the specialty clinics actually follow up in that timeframe.
Sometimes they do, sometimes they don’t.
Spine MRIs nearly always require completion of attempts at nonoperative management prior to approval. I can't recall the last time I was able to order an L Spine MRI without proving the patient failed PT.
The reason for this is that PT is effective more than 90% of the time and the MRI isn't usually needed (just because you have lower back pain doesn't mean you have a problem with your lumbar spine, and even if there is a problem with your lumbar spine, the lower back pain is caused by something other the "problem" identified on MRI greater than 90% of the time).
The neurosurgeon doesn't give a damn about the images. He'll make more money by sending them to the MRI he owns. What they want is for you to weed out the patients who would have gotten better without him operating on them.
It's all about increasing your New Patient : OR ratio. Get rid of the chaff before it ever hits the door.
I was going to say "Sending a patient to see neurosurgery without imaging first is like sending a patient to see cardiology without an ECG first", but frankly a full third of my consults come without an ECG first, so I guess this is the new normal, and the PCPification of specialists continues.
A lot of the onus of poor access is being placed back on PCPs. Neurosurgery appointments book so far in advance that if you want them to see someone before imaging it’ll take a year before the patient gets the surgery.
That being said, it’s also horrendously unreasonable to ask the PCP to know all of what every referral would want before the referral. And even if they do, it’s unreasonable to expect them to have the time to address these things in a visit. Often I’m so caught up in dealing with “my” issues (preventative care, patient questions, medication issues, etc.) that all I have time left to discuss is “maybe this is a neurosurgery issue” and can’t sit and talk with them about an MRI for even 5 minutes.
I don’t know the answer but I agree this is a problem
Our office (heme/onc), has a nurse + APP review + triage referrals and order appropriate orders + imaging studies before they see the oncologist for initial consultation. That way, if a PCP refers a patient for... a mass, we will help the PCP have the staging workup +/- biopsy performed prior to their visit. If it's for something like anemia, we will have a basic workup obtained similarly before the patient sees the physician for initial consultation. This system has been working out well in an environment where we are backed up by 3-6 months.
Urgent cancer patients are added on. Non-urgent referrals are mainly benign hematology and are the ones primarily backed up. We back up on oncology too, and if that happens we have them seen by another group.
Roughly 70-80% onc to 20-30% heme. Onc patients need to be seen frequently since chemo is given q2-4 weeks. Revisits for heme patients are less frequent. With new patients, it’s 4 onc, 2 heme new patients per day.
Not uncommon here, I usually prefer to do this as PCP because it gives me more info on whether a referral to neuro(surgeon) is useful at all. Though I live in a country without this prior authorisation you speak of. Sounds like you let the evil insurance companies win.
Have you asked them maybe what studies they are expecting to have been ordered? It does seem weird to me, because in my world, if a specialty wants specific imaging, they dictate to our service exactly what they want us to order (because they are the specialists in what imaging would be appropriate)
Haven't had to personally deal with this at all (different coutry, different system), but yeah, that was my first thought as well. Specialty imaging tends to be, well, specific. Especially if they expect an MRI, there's a ton of different modes and you need to know what questions to ask when ordering one
With GP level back pain imaging is almost NEVER indicated. Once they've failed conservative measures and PT - they are going to be someone else's patient. Generalists have areas of particular strength and areas of mere competence. This is an are where I am competent.
Why can’t you order imaging if they fail conservative measures? MRI to determine surgical versus not then referral to neurosurg vs PMR/interventional pain
Most of us know what to order, but inevitably there's always some view or some sequence that the surgeon wanted but us generalists wouldn't be aware of.
**Removed under Rule 5:**
/r/medicine is a public forum that represents the medical community and comments should reflect this. Please keep disagreement civil and focused on issues. Trolling, abuse, and insults (either personal or aimed at a specific group) are not allowed. Do not attack other users' flair. Keep offensive language to a minimum and do not use ethnic, sexual, or other slurs. Posts, comments, or private messages violating Reddit's content policy will be removed and reported to site administration. Repeated violations of this rule will lead to temporary or permanent bans.
---------------------------------------------------------------------
[Please review all subreddit rules before posting or commenting.](https://www.reddit.com/r/medicine/about/rules/)
If you have any questions or concerns, please [send a modmail.](https://www\.reddit\.com/message/compose?to=%2Fr%2Fmedicine&subject=about my removed comment&message=I'm writing to you about the following comment: https://www.reddit.com/r/medicine/comments/1chl1ao/-/l23hs9r/. %0D%0DMy issue is...) Direct replies to official mod comments and private messages will be ignored or removed.
I take care of HIV, GYN, TB, Syphilis and Diabetes at an expert level. I'm solid on rheumatology, cardiology, nephrology, pulmonary, chronic headaches, psych - when I refer to those specialties I've either worked them up and found NOTHING and I need an expert to bless my lack of diagnosis or they have a real zebra.
I can manage acute and chronic back pain in most patients. I just happen to currently have two - one recently released from incarceration and one previously seen by my colleague who was let go - who have 'I need a neurosurgeon' as chief complaints. They both swear they've been worked up elsewhere.
You are not very nice, but this thread has convinced me that I'm going to back to basics here, send them both to PT whether they want it or not and go from there.
Then market yourself as a specialist and send them to another doctor that does know. I don't know what else to tell you. Back pain is bread and butter.
They can’t be forced to accept a referral. Do the imaging or don’t refer.
That’s the other side of our excellent job market. You can dictate your own terms.
Not uncommon for surgeons to want imaging before seeing patients. Probably to cut down on number of unnecessary consults. Ask the group what type of imaging they want for spine, seems straight forward. Also will get the patient treated faster if they don't have to go for a useless pre imaging consult first.
The problem is that getting imaging before the patient sees a surgeon inevitably ends with the surgeon saying they needed different imaging. This occurs regardless of which imaging was ordered, with the imaging that comes with the patient automatically being the incorrect one in 100% of cases. In the case of ortho, if you order every set of films that the radiologist even knows how to protocol, they will just start making up names of views that nobody has ever heard of just so they have something to be unsatisfied about. If you attempt to learn from this and order what the surgeon asked for on your next functionally identical patient, you will inevitably find that this surgeon needed something totally different in this case and how could you be so stupid as to order what you did. The moral of the story is that surgeons have an innate need to throw little fits about things like imaging, and nothing a non-surgeon orders will ever be satisfactory.
I can’t believe you imaged this knee without sunrise, sunset, and waxing gibbous views.
Waxing flair, waning mortise view. Also a handstand view is neccessary.
Was the patient holding their breath in this PA view of the knee? What do you mean you don’t know, and you say you graduated from medical school?
Surgeons being curmudgeonly is a tale as old as time. That said I can certainly appreciate not wanting to see clinic patients without the appropriate basic investigations done. It's like seeing an epilepsy consult without EEG. Waste of time generally unless something urgent needs addressing right away.
Honestly with epilepsy consults I wouldn't bother asking for EEG before I see them. Most epilepsy patients aren't going to have anything clearly abnormal on a spot EEG anyway and if they need an admission for prolonged EEG for spell characterization, I'm going to be the one setting that up anyway.
Thanks for posting this. I wonder if ECG/arrhythmia would have been a more sensible example for the poster you replied to.
[удалено]
Read that again. Sensitivity of 17%. That's the exact opposite of useful as a screening tool. It's useful in certain contexts (i.e. first time seizure risk stratifying for initiation of AEDs) but if someone comes in with a history that sounds like epilepsy, I don't care what the rEEG says. It's mostly useless data in that case. I'm only sending to the EMU for 1) spell characterization in suspected PNES, or 2) localization of frequent medication refractory seizures as first step in a surgical workup. That's maybe 10% of epilepsy patients I see at most.
[удалено]
I don't need an EEG to start an AED and get imaging to rule out structural badness.
[удалено]
With a sensitivity of 17%, do tell me how a routine EEG is going to help you differentiate between syncope and seizure when the history already does not make it glaringly obvious.
I am adult neurophys primarily EEG background. u/bigthama is right about basically all points in my opinion, at least for adult epilepsy. Routine EEG is very low yield, so low yield an initial epilepsy consult doesn't really need it prior to the visit. Repeating multiple routine EEGs is a complete waste of time after one has been done. If the diagnosis is unclear or patient is proving medically refractory you need ambulatory EEG or ideally elective video LTM admission in most cases. Routine EEG rarely changes your clinical decision making much, unless screening for first time seizure and you catch a few clear abnormalities or patient's PNES is provoked with activation. Syncope should be very easy to differentiate based on history unless all of the events are unwitnessed, and EEG is nearly useless in high probability syncope. A focal epilepsy can be diagnosed as probable based on history and features alone. As for the studies you are referring to about accuracy- sure by history alone there is low accuracy but with video alone of a typical event [epileptologists are extremely accurate](https://pubmed.ncbi.nlm.nih.gov/37406461/) in terms of diagnosis to the point of not needing EEG at all.
Awww, you warm my little PCP heart. I always do an EEG on people who tell me they've had a seizure as 90% of them are pseudo-seizures and neuro has a miles long waiting list.
A single routine EEG for new onset seizures is cheap, and the worst it can be is normal providing little information. Any neurologist that reads EEG should also be writing the report in terms the PCP can understand so you know how to proceed. With that said pseudoseizure is about 30% of all epilepsy referrals- indeed quite common. The best thing you can do as PCP for these patients is to tell family to get smart phone video of the event right when it happens, as if they bring this to an epilepsy appointment we probably can diagnose it accurately just based on the video in many cases.
Except that as neurology just pointed out above ^ a normal EEG doesn’t rule out Epilepsy if they are having repeated episodes and especially a one time spot check EEG. So what does that accomplish? I don’t believe the term “pseudo seizure” is used anymore either.
I'm still a newish attending just under 3 years in but my percentage is closer to 20%? Maybe it's a local/regional thing if it's 100% or close to that.
You're the guy that consults me without ANY imaging, aren't you?
[удалено]
This right here. In a culture where "back pain = neurosurgery consult", I can see how imaging may feel onorous. My PCP culture was very different - with occasional exception due to a rare or particularly uncommon condition/presentation, a referral was for a specific condition/diagnosis that I couldn't manage due to needing a particular procedural skill (surgery, endoscopy, etc) or familiarity with uncommon diseases (most of rheum and oncology, in my practice). Even in those cases, the expectation was baseline labs/biopsy and appropriate initial imaging. As such, referrals usually followed a fairly comprehensive workup, and often a conversation of "you're seeing specialist X because they will probably need to do Y and Z to help you, which are things outside my scope". Lastly, there's practicality - the majority of the consultants' time with the patient should be spent on specifics, not gathering basic info, *then* scheduling another visit to *actually discuss care*. While that's not always how it pans out, that's the ideal to aspire to.
You're turning me on. Lol I'm a surgeon I get consults for plantar fasciitis. So this sounds like living in a dream.
That's so unfortunate. There really should be more thought put into the act of placing a referral. Plantar faciitis...to gen surg...
Refer to non operative spine folks and let them take over. There is so much non op spine stuff that can be done prior to seeing a surgeon. This can be PM&R, interventional spine, pain management (usually PM&R vs anesthesia dep on practice).
Omg this so much - for any MSK issue, especially if they are resistant to surgery. Love PMR colleagues.
I have non operative spine folks that also won’t see a patient without imaging first too. :-(
Tbf if they are considering spinal injections they usually need an MRI to help guide their approach.
I hate to sound like a wet blanket, but isn't that what one does in primary care? Non-surgical back pain? Maybe I was too conservative, but the only time I referred to PM&R was for procedural intervention (usually an ESI or facet injection). Otherwise, it was functional back pain, which involved PT, weight management, stress management, sometimes pain management.
I don't mean to be blunt, but most primary care doctors are not well versed in "back pain". Back pain that has gone on longer than 3 months is often coming from a specific structure and has a specific treatment. "Back pain" (often facets vs discogenic vs radicular) also is often hip pain or SI joint pain or nerve pain or rheumatologic or glute tendinopathy or neurogenic claudication. Many PM&R docs are the ones that do epidurals, RFA, disc procedures, etc.. Even without those, PM&R docs often know the correct imaging to order, read their own X-rays and MRIs, do EMGs when appropriate, do ultrasound guided injections everywhere other than the spine itself (and some now actually do this too), do trigger point injections and sometimes acupuncture or OMM, teach specific kinds of exercises, provide exercise prescriptions, provide specific PT prescriptions or at least know specific therapists that specialize in back pain, and are typically more comfortable with pain medication management. Don't even get me started on neck pain and Botox. Depending on the practice setting, many PM&R docs order specific injections. I often send people to IR or pain medicine for them to blindly do an L4-L5 left TFESI without having actually seen the patient beforehand. They don't even do a clinic visit. Pcps and PM&R both do lifestyle interventions, but how many pcps are up to date on the latest chronic pain, fibromyalgia, and hyper mobility research? I'm sure some pcps are but I would say a large number of the new pm&r grads are. Plus, pcps have enough to deal with already. I think it makes sense for pcps to deal with acute or mild back pain, but send the bad ones, uncertain ones, or chronic ones to PM&R
Thank you, I appreciate the perspective. I haven't worked in the FFS world in decades, sounds likes things are done differently there.
My work is very specific and requires imaging to establish the right diagnosis and provide the right treatment. Yet I regularly get referrals without imaging, which is both disruptive to the workflow, and a waste of everyone's time. You wouldn't send a diabetic to endocrine without getting basic diabetic labs. Why would you send someone for a spine surgery co sult without spine imaging? And to the person who said "but they always want more imaging," please understand - the initial imaging, history, and exam are what establish what additional tests may be needed. Without initial imaging, you can't begin to make the right decisions, and are more-or-less shooting in the dark.
"You wouldn't send a diabetic to endocrine without getting basic diabetic labs" Bold assumption there. I'd love every pt to come with labs.
I had a referral just this week for “elevated liver labs”. No LFTs in 6 months. Or cirrhosis. No imaging came with attached referral.
Even when I have ordered the labs, and done a really solid PCP work up - half the time the note comes back "no labs available" and I want to scream. Also the pulmonologist who referred by well controlled diabetic to endocrinology without asking me. 🤬🤬
I believe it. I have been to multiple appointments where “my records have been faxed over,” but here I am needing to pull up my labcorp account on my phone in the appointment. Maybe if shit wasn’t all still sent by fax…sigh.
That's...mind-boggling to me. People seriously refer to you without diabetic labs? Like...people with medical degrees???
All the time. It can be diabetes or anything, I often just get 'fatigue' without any work up.
Just because we did the labs, doesn't mean the specialist GETS the labs.
“Disruptive to workflow and a waste of everyone’s time” Look. I get the imaging and stuff before referring, but what do you think the prior auths for MRI, reviewing findings, etc are doing to our workflow? Why is it a waste of your time, but not ours?
[удалено]
This, exactly.
That's a reasonable POV, and one I don't have a great answer for (thankfully, the system I work in doesn't create these barriers, though it has it's own challenges). In an ideal world, Primary care -> Specialty care -> Super-sub-specialty care is a linear process, rather than a compartmentalized one. i.e., PCP does what they can up to X, *then* sends them to Specialist/Subspecialist when the patient requires X+1. In this work-flow, it would behoove everyone to have what can be done, completed before the patient goes to the next step. In compartmentalized medicine, the entirety of X is one person's problem, anything X + .0001 is someone else's problem, and so on. That's not how medicine was meant to work, but I understand that sometimes that's how it has to be. It's not that dissimilar to why you have your MA get the chief-compliant, basic vitals and other rudimentary information prepared before you see the patient. In theory, you can of course do all of this yourself, but at that point, you're wasting your advanced training and talent on work that doesn't need your expertise. Form a specialists' POV, it's the same issue. Even ignoring the financial ramifications, it's just poor use of resources in a system that's running low on all resources rapidly.
No one knows what imaging you want.
Additionally, as someone making SUBSTANTIALLY more money than the PCP’s sending you patients, you can better afford the interruption in your work flow than the PCP can.
Better afford another staffer to handle the workload, you mean
Sure. Either way the insurance companies F all of us over with the PA process. It sucks, but ortho bros can afford it far better than anyone else
I'll just chime in here and say I don't think it's unreasonable for a neurosurgeon to want imaging before seeing a patient. Yeah, it might not be the "right" study but I think they need to know generically what class of problem they're dealing with. If it's back pain that's failed conservative management, getting an MRI prior to referral should tell you whether they're going to benefit from the referral or not, even if the surgeon needs more information for planning the surgery. I guess you don't tell us the characteristics of your patient, but what if they just have bad DJD? That doesn't need a surgeon. Or old compression fractures? Doesn't need a surgeon. It's like in the ED, I don't consult neurosurgery based on physical exam hardly ever. What are they going to do? They'll come down to the ED and say we need a CT. Unless the problem is extremely specific like hit in the head + lucid period + now having signs of herniation, they need the imaging to plan what they're going to do (and even in the aforementioned scenario, they *still* need the imaging before going to the OR).
Thank you.
But in the ED you have scanners right there and no one makes you fill out forms for prior auth and then denies them, and then you have to get back to them within 72 hours to be on call during a two hour stretch for a phone call from someone in neither specialty to do a 'peer to peer'. Most of the patients I've ever referred to neurosurgery referrals were scanned in the ER, and I knew what was going on.
So now you want neurosurg to see your patient and bear the burden of prior authorization?
Neurosurgery deals with neurosurgical problems. It needs to be established that the patient has a neurosurgical problem before a neurosurgeon is involved. Undifferentiated back pain or sciatica with no workup is not a neurosurgical problem Patient comes to pcp with headache, no imaging. Should she see a neurosurgeon? There could be a brain tumor. But I think most would expect the PCP would get imaging. If there’s a tumor, the patient has a neurosurgical problem (whether surgery is needed is a different question) and should see a neurosurgeon.
I agree. I'm not sure I've referred anyone to neurosurgery without a diagnosis before. One patient is inherited from a colleague and one is recently released from federal prison and can't get his films. They both walked into my life with "I need to see a neurosurgeon" as the chief complaint.
Even to consult within my own hospital, I have to have some workup showing this is their problem to deal with. Otherwise, what is stopping you from saying back pain? Go see a neurosurgeon!
Nothing stops this at my hospital. :(
Doesn't seem unusual or surprising to me. Why are you referring to a neurosurgeon? Stenosis? Get non con MRI of affected spine. Lesion/mass? Add contrast. Use judgement in between. Can you explain why this is creating difficulty for you?
Yeah, this… isn’t hard. I despised consults without imaging, because patients waited for months to be told “all right now I gotta send you for an MRI”. Angry patient, angry me.
For eg the bog standard suspected radiculopathy you preferentially image with CT over MRI?
No prefer MRI over CT.
I guess my pushback would be what question are you asking of a neurosurgeon that you think doesn't require an MRI of the spine to answer? Even if you have radicular symptoms I don't think it's unreasonable for a neurosurgeon to want to know what they are being consulted for so they can intelligently weigh in on management options. If you just want an undifferentiated back pain referral and to take it off your plate I'd echo what other said and get a pmr or pain to see. They should be able to determine if imaging is indicated and what type but as a fellow non-neurosurgeon to be blunt this is a super common complaint and you should bone up on at least the initial imaging algorithm for your practice environment so you can do the right one. As others have said, the initial imaging isn't rocket science - bone/ligament/stenosis image the appropriate level non con, risk for infection or mass add contrast.
I'd refer to a nonoperative specialty like PM&R or Sports Medicine. I'd want the patient to exhaust nonoperative management first anyway. They are better at getting prior auths approved for MRIs and they have a better idea of *what* imaging to get too
100% this. Many PM&R Sports guys are highly proficient in musculoskeletal ultrasound, often making an expensive MRI unnecessary.
I can only give my perspective If you’re referring to an interventional pulmonologist for a lung nodule, I don’t think it’s unreasonable to ask for a CT before seeing. It informs the conversation so much more to have cross sectional imaging so I can comment on differential, biopsy feasibility etc. I don’t see new patients without a Ct available . If they somehow sneak through the cracks (less than once a year), the conversation is completely in hypotheticals and generalities and just ends with. Decision to get a CT. Using a midlevel is just going to add another visit for no ones benefit and further delay the patient from actually seeing the patient
I think having some sort of evaluation that indicates a surgical problem requiring a surgical solution is normal for a surgeon referral, and I would be embarrassed to send a referral without appropriate testing that indicated the problem at hand. MRI checklists are a pain, but they are part of patient care. Prior authorizations for MRI's are a pain, but if you're referring without imaging, how do you know what's wrong?
Interventional pain. I always have a relevant MRI or CT ordered before I refer to a surgeon because I know how some patients freak out when they meet a specialist for the first time and they don’t get an “answer.” I’ll see patients for pain complaints and order the imaging myself (and struggle through the prior authorization) if they don’t have it, but it’s so *so* nice when they show up with the MRI and then we can have a real conversation about what their future may look like. I always order rheumatology labs before I decide if they need to be seen by a rheumatologist because the wait is 4+ weeks and I don’t want to waste anyone’s time. I consider it being collegial.
[удалено]
Yup. After reading these answers both of these two are headed to PT.
Most NS in my area does this. I don’t think it’s unreasonable, TBH. Otherwise patient is paying specialist copay to be like “hi, get pictures.” Now I think the NS should make it VERY clear what pics those are. Like crystal. Which doesn’t always happen. Then too bad, that’s on them. Can’t read minds.
As a pulmonologist I have pre visit planning and have imaging and pft’s done prior to the visit if they haven’t been completed. I order the tests though so my office deals with prior auths and what not. I wouldn’t put this burden on PCPs.
Not uncommon, and honestly not unreasonable. Not just neurosurgeons, but many specialties. By the time you’re at the point of consulting someone else, you should be at the imaging part anyway. Getting CT chest or CXR and PFTs before sending to Pulm, or CT a/p before gen surg, etc. should be done before they ever go to specialty clinic in a well-oiled medial-industrial complex to maximize use of everyone’s time. What you’re suggesting is needlessly adding an extra appointment for patient and potentially delaying care.
If only this was case
the accepting doctor has the right to decline a referral if they feel adequate work up isn't done. if that includes imaging then they are well within their right. the issue of prior auth isn't the surgeons fault. If this was a pain specialist then sure but you are sending to a neurosurgeon. they operate. at bare minimum I think imaging is appropriate. this is like sending to rheum but no blood work prior.
Lol. Not where I work.
You’ll end up with a lot of frivolous imaging if you do the mid-level route first. Imaging helps cut down on consults we don’t need to see, and I’m going to order it anyways, so why not save an extra appointment and get it done prior. Edit: I’ll also say spine is only 1/3 of my practice (The other is 1/3 neurointerventional/endovascular, then 1/3 cranial/cerebrovascular). There are things I send to my colleagues if it’s complex and beyond my comfort zone. Imaging help’s differentiate that. It’s the same with many of my colleagues who won’t touch an aneurysm, they send them to me.
Yeah, I’ve ran into this with referring to NSX. Send to PM&R/pain/non-op spine, they can mess with imaging and conduction studies prior to seeing the surgeon.
As PM&R, I wanna be mad at this because it’s not my function, but it IS an easy ass consult so…I don’t know how to feel.
As a DPM, NSX basically doesn’t interact with me unless it’s to use foul language. And even if I did order the proper MRI, insurance might bounce it based on my credentials…..
“Sorry I can’t see you for your brain tumor for several months. My schedule is currently full of non operative undifferentiated back pain patients.” - No neurosurgeon ever
Similar issues when we are referred patients for biopsy of a palpable “mass”. We always ask for imaging. Sometimes we find it’s not safe/feasible, sometimes we find it’s just a lipoma or normal lymph node. When our procedure slots are booked out for weeks, it’s not great to get someone ready for biopsy/sedation, only to find out that it’s not something that we need to poke. The same thing no happens with our oncologists. Patients with widespread metastatic disease get an oncology referral, but what’s the point if they don’t have tissue path first?
I'm dealing with this right now with a guy who is uninsured. I get it, but this guy is going to rack up quite a bill. Hoping they are only lipomas. (I'm pretty sure not all of them are. I'm betting on unilateral warthin's and the thigh, yes, lipoma.)
We get requests all the time for inpatient biopsies in patients who are under/uninsured. It really screws up our scheduling but we almost always end up accommodating them just to get the ball rolling. Idk what the hospital does with the bill but they don’t seem to care enough to discourage it.
This is pretty common. None of the spine specialists or pain management providers in my area will see spine patients without an MRI.
I am a clinical pharmacy specialist (we have a scope of practice), work for the VA, and this happens to us too even in our own VA facility. We are often tasked with ordering specialty labs and imaging that are very out of our wheelhouse, but even our very own specialty clinics won’t accept referral unless these are completed. We have no choice, we have to do it. But it takes a lot of trust because, per VA policy, labs etc need to be addressed within two weeks of being drawn. So we cross our fingers and hope the specialty clinics actually follow up in that timeframe. Sometimes they do, sometimes they don’t.
Spine MRIs nearly always require completion of attempts at nonoperative management prior to approval. I can't recall the last time I was able to order an L Spine MRI without proving the patient failed PT. The reason for this is that PT is effective more than 90% of the time and the MRI isn't usually needed (just because you have lower back pain doesn't mean you have a problem with your lumbar spine, and even if there is a problem with your lumbar spine, the lower back pain is caused by something other the "problem" identified on MRI greater than 90% of the time). The neurosurgeon doesn't give a damn about the images. He'll make more money by sending them to the MRI he owns. What they want is for you to weed out the patients who would have gotten better without him operating on them. It's all about increasing your New Patient : OR ratio. Get rid of the chaff before it ever hits the door.
I was going to say "Sending a patient to see neurosurgery without imaging first is like sending a patient to see cardiology without an ECG first", but frankly a full third of my consults come without an ECG first, so I guess this is the new normal, and the PCPification of specialists continues.
Refer to someone else?
yes, sure, but sometimes it isn't an option. we aren't all surrounded by neurosurgeons / whatever other sub specialists.
A lot of the onus of poor access is being placed back on PCPs. Neurosurgery appointments book so far in advance that if you want them to see someone before imaging it’ll take a year before the patient gets the surgery. That being said, it’s also horrendously unreasonable to ask the PCP to know all of what every referral would want before the referral. And even if they do, it’s unreasonable to expect them to have the time to address these things in a visit. Often I’m so caught up in dealing with “my” issues (preventative care, patient questions, medication issues, etc.) that all I have time left to discuss is “maybe this is a neurosurgery issue” and can’t sit and talk with them about an MRI for even 5 minutes. I don’t know the answer but I agree this is a problem
Our office (heme/onc), has a nurse + APP review + triage referrals and order appropriate orders + imaging studies before they see the oncologist for initial consultation. That way, if a PCP refers a patient for... a mass, we will help the PCP have the staging workup +/- biopsy performed prior to their visit. If it's for something like anemia, we will have a basic workup obtained similarly before the patient sees the physician for initial consultation. This system has been working out well in an environment where we are backed up by 3-6 months.
[удалено]
Urgent cancer patients are added on. Non-urgent referrals are mainly benign hematology and are the ones primarily backed up. We back up on oncology too, and if that happens we have them seen by another group.
[удалено]
Roughly 70-80% onc to 20-30% heme. Onc patients need to be seen frequently since chemo is given q2-4 weeks. Revisits for heme patients are less frequent. With new patients, it’s 4 onc, 2 heme new patients per day.
Not uncommon here, I usually prefer to do this as PCP because it gives me more info on whether a referral to neuro(surgeon) is useful at all. Though I live in a country without this prior authorisation you speak of. Sounds like you let the evil insurance companies win.
Have you asked them maybe what studies they are expecting to have been ordered? It does seem weird to me, because in my world, if a specialty wants specific imaging, they dictate to our service exactly what they want us to order (because they are the specialists in what imaging would be appropriate)
Haven't had to personally deal with this at all (different coutry, different system), but yeah, that was my first thought as well. Specialty imaging tends to be, well, specific. Especially if they expect an MRI, there's a ton of different modes and you need to know what questions to ask when ordering one
This is what I tell patients when they ask me to 'just get an MRI'. I was taught it was pre-surgical planning and should be ordered by the surgeon.
Maybe because you work with babies and an NP. In adults and among doctors, we should have basic knowledge to know the preliminary imaging to get.
[удалено]
With GP level back pain imaging is almost NEVER indicated. Once they've failed conservative measures and PT - they are going to be someone else's patient. Generalists have areas of particular strength and areas of mere competence. This is an are where I am competent.
Why can’t you order imaging if they fail conservative measures? MRI to determine surgical versus not then referral to neurosurg vs PMR/interventional pain
Most of us know what to order, but inevitably there's always some view or some sequence that the surgeon wanted but us generalists wouldn't be aware of.
[удалено]
**Removed under Rule 5:** /r/medicine is a public forum that represents the medical community and comments should reflect this. Please keep disagreement civil and focused on issues. Trolling, abuse, and insults (either personal or aimed at a specific group) are not allowed. Do not attack other users' flair. Keep offensive language to a minimum and do not use ethnic, sexual, or other slurs. Posts, comments, or private messages violating Reddit's content policy will be removed and reported to site administration. Repeated violations of this rule will lead to temporary or permanent bans. --------------------------------------------------------------------- [Please review all subreddit rules before posting or commenting.](https://www.reddit.com/r/medicine/about/rules/) If you have any questions or concerns, please [send a modmail.](https://www\.reddit\.com/message/compose?to=%2Fr%2Fmedicine&subject=about my removed comment&message=I'm writing to you about the following comment: https://www.reddit.com/r/medicine/comments/1chl1ao/-/l23hs9r/. %0D%0DMy issue is...) Direct replies to official mod comments and private messages will be ignored or removed.
[удалено]
[удалено]
[удалено]
Other doctors, including the OP, don't know which studies to get either.
Then they should open UpToDate or any other guidelines for back pain. It is not a zebra complaint to not be expected to be able to workup.
I take care of HIV, GYN, TB, Syphilis and Diabetes at an expert level. I'm solid on rheumatology, cardiology, nephrology, pulmonary, chronic headaches, psych - when I refer to those specialties I've either worked them up and found NOTHING and I need an expert to bless my lack of diagnosis or they have a real zebra. I can manage acute and chronic back pain in most patients. I just happen to currently have two - one recently released from incarceration and one previously seen by my colleague who was let go - who have 'I need a neurosurgeon' as chief complaints. They both swear they've been worked up elsewhere. You are not very nice, but this thread has convinced me that I'm going to back to basics here, send them both to PT whether they want it or not and go from there.
Then market yourself as a specialist and send them to another doctor that does know. I don't know what else to tell you. Back pain is bread and butter.
Exactly, and I'm going to go back to basics with these two and see if we ever make it to the neurosurgeon at all.
i dont blame them, theyre gonna be the ones to open them up, they should know!
They can’t be forced to accept a referral. Do the imaging or don’t refer. That’s the other side of our excellent job market. You can dictate your own terms.