It's the truth that the cost of healthcare is skyrocketing, and Medicare (and private insurances) is spending astronomically higher amounts of money for its members. While this is probably multifactorial (in no small part due to Medicare fraud methinks, but I shall blog about that some other day), on a week like this I couldn't help but wonder how much us doctors contribute to that when we don't stop for a moment to think.

This has been a particularly frustrating week, as I seemed to have a disproportionately higher number of what I consider to be inappropriate endocrine consults. I was averaging about 3 consults a day of medical issues unrelated to what I can help the patient with. These included:

• High CK levels- 8x above normal and having proximal muscle weakness. Suspecting polymyositis, and suggested he sees rheumatology, the people who actually treat this
• Depression
• Fatigue- with the usual normal TSH levels (and Vit D)
• High Total T4 in pregnancy (but normal TSH)- even my 3rd year med student could remember that TBG levels are increased in pregnancy hence the TT4
• Anemia (low MCV, ferritin, with complains of melena)- Dear Doctor, your patient has a GI bleed!
• Neck pain- apparently this patient's doctor mistook the left sternocleidomastoid for the thyroid, or something

I hate to be judgmental of my peers as I don't think I'm all that bright myself. But I caught myself wondering if this was from perhaps the lack of better ideas (maybe the GP was at the end of the rope) or just poor medical knowledge. Or maybe the patient insisted on the referral.

Unfortunately, I'm not business-smart; I don't appreciate seeing patients for the sake of making money- I consider myself oldschool- I want to help patients with real hormonal disorders.

Consider this- a Level 4 Consult (99244) has a reimbursement fee of $168. This would be the norm for the patients we see.

A Level 5 (99245) gives a reimbursement of $218. If we are dealing with a high risk situation, or if I am required to review/order radiologic tests then we typically mark it a Level 5.

(And no, that's what the system charges- not what I take home per patient)

And so, can you imagine what this must be costing the whole damned system if one single specialist is 'wasting' $500-600 a day seeing unnecessary consults? Clearly, this must add to the healthcare economic burden. And what about the cost to the patient? They have a copay and thus don't pay the full amount; but what about the emotional costs when they have their hopes up only to find out you cannot help them? Or to have them drive 2 hours to see you for hypothyroidism only for you to say that their TSH was 1.12 and FT4 1.3 (normal) just 5 days ago? 

This is one reason I miss working at an academic center. There seems to be more careful thinking rather than the kneejerk "Refer to XXX to check for YYY". Like, if an internist was considering a diagnosis of Cushing's, he'd order the test and if abnormal only then would he refer. Or, rather than sending your fatigued patient to the endo to see if the thyroid was working fine, do the test first as many people with fatigue will not have hypothyroidism.

Instead, I've been horrified by some of the clinical notes I've seen as part of my consults. Like having a GP refer a patient to 3 different specialists to 'rule out' 3 different things all from the same clinic visit! Whatever happened to the art of being a doctor?

And so, as much as I enjoy my work, there are times when I do get frustrated with how the system can be so flawed.