I agree with Catherine.  Written feedback on all consults, not just from
LCs, is so important to helping us develop as providers. In fact, in order
to bill as a consult (which reimburses as a higher level than a standard
visit), part of the service includes sending a letter back with your
findings to the referrer (per the coding books).

As far as Arly's question, I think it's not so much writing an order
forbidding consults, as much as it is not writing an order TO consult.  I
don't write orders forbidding the lab work, etc., I want done, just what I
do want done. Again, I'm supposed to justify the medical necessity of stuff
(labs, x-ray, consults, meds, etc.) I order, because my name's on the chart
as the Provider In Charge.

I suppose I "forbid" care when parents bring their kid in with a viral cold
and demand antibiotics, which I refuse to give them; or say, demand a chest
x-ray for a child whose respiratory rate is 18, lungs are clear, nary a
cough.  I tell parents that I can't in good conscience certify that these
things are "medically necessary," or even helpful or in the best interests
of the child, to do.  Parents sometimes storm out of my office and go to the
ER to get their Zithromax/plain films.  Because it is so important to trust
your pediatrician, and since these parents obviously don't or can't, we will
discharge them from our practice for this behavior.  But technically we
can't "forbid" them because it's so easy to switch doctors to find someone
who will give them what they demand.

As far as forbidding care from certain providers: there are a few
practitioners in our surrounding area who FRIGHTEN me.  They are not limited
to MDs and also include a chiropractor, an herbalist, and a counselor.  I
would never allow these particular individuals near my sick patients in the
hospital, and I certainly don't encourage my patients to see them when
they're well, but quietly refer them elsewhere.

There's a difference between not referring to a particular provider, and
then not referring to anyone in a particular DISCIPLINE (e.g. never
referring to ANY LCs, not just a particular one in the community that you
have a conflict with, etc.)  In some cases, it seems like one and the same
if you live in a small town.  E.g. if your town has one nephrologist and
he's terrible, you might say "No Nephrology Ever!" (fortunately ours here in
town is wonderful :)

Suzanne Berman, M.D., FAAP
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