Friday, April 5, 2013

Doctors and Referrals

Dear Doctors,

I really respect the training that you as individuals obtain. It is not easy to go to college for 4 years and major in a science degree. Then take the MCAT. Then go to medical school for 4 years. Then get 3+ years of residency training to take the Boards and get your official certification as a doctor in your specialty. I only have a Bachelor's degree in Psychology & Social Behavior, a Master's Degree in Public Health, a Licensure in California Registered Nursing, and am completing my Second Master's in Advanced Practice Public Health Nursing, which when it is all said and done equates to about 9 years of advanced education beyond a high school degree. Not to mention the extra work experience that I have in the Peace Corps, AmeriCorps, at UC Irvine Medical Center, at UC Irvine Health Education Center and the endless CEUs from conferences and work trainings.

But enough about me. My goal is to help patients be healthy and keep children safe as a child protective services public health nurse. Your job as a doctor is to also help patients be healthy. As (not just) a nurse case manager, I am granted the position to case manage complicated health care for children with various diseases, medications, specialty appointments, and providers. I do home visits, unlike you. Where you see patients 15 minutes per visit maybe a few times a year, I see patients in their home environments for an hour at a time for several weeks, months, even years. I get to know what they like to eat and where they sleep and if they are warm at night. Where you see "non-compliant" parents who can't give their child with Asthma the medications in the right way, I see an overburdened parent with several children living in poverty. They are restricted by language or culture or literacy. They are scared, overwhelmed, frightened of their child's disease and medications. They are not highly educated. They are confused by all of the complicated, verbose, and wordy things that all of the nurses and doctors have told them in the past. They are overwhelmed by the gargantuan system that is Healthcare in America today. They are sidetracked by family members who demand their time and attention or serve as caretakers for elderly parents. And when the day-to-day basic survival things that need to get done like eating, sleeping, and showering for several children, why would eating healthy, exercise, de-stressing, getting educated, getting work training, or being proactive be on their minds, especially if living in a low-income neighborhood? Do you see the whole picture now? Parents and patients don't want to be difficult and they don't want to be "non-compliant", but there are sometimes A LOT of boundaries to over come. I try to help families over come as many as they can to get them to a better place, to be less busy, less overwhelmed, and freer to be healthier children, healthier people, and healthier families for the future.

I spend part of my day in the office being the central point for children in foster care and CPS. When they have been medically neglected, it is my job to make sure they are getting the treatment they need to not just survive but to also thrive. So when I have made the dozens of phone calls to insurance, clinics, doctors, nurses, community resources, social workers, and my patient still hasn't gotten that specialty appointment please do not belittle me by saying things you don't know or haven't bothered to ask about:
  • First, I help to coordinate the evaluation for the child with the diagnosis as stated by mental health professionals and educators who spend much more time with that child than you do. You should know that as a doctor that sometimes to diagnose a diseases you've got to rule out others, so we have to start with some kind of idea of what the child might have. I'm not a doctor and I don't diagnose. So when I ask for a referral for X evaluation, it's for a reason. I'm not making things up, someone else in the child's CPS team asked for it.
  • Second, when I call a clinic and they say that they don't take CPS cases, it's because they have a clinic policy to not take CPS cases. I can't change that. I shouldn't have to call back and clarify and act as the investigator to find out who told me that, the clinic told me that and as Sweet Brown has stated "ain't nobody got time for that".
  • When a clinic says that they have a 10-month wait list and you tell me that you don't believe that what I've told you is true, that's insulting.
  • When the clinic tells me that they will see the child and needs a referral from you and I ask you for the referral, it's for a good reason that I asked you for a referral. I'm not pulling tricks out of my bag because I just want to create more work for you and for me. Had I been able to do the referral myself, I would have done it buddy. And had the clinic told me that they don't see kids that age, I would have not asked you for the referral to that clinic.
  • Please don't tell me whereto ask you where to make referrals based on the fact that that specific clinic is terrible at communicating with you. If it's best for the child, make the referral!
  • Just because you make a referral, doesn't mean that the child has to be seen there. You are not God. You do not rule all of the clinics or the health insurance. It's a referral, kind of like a suggestion to that clinic that they should see your sick child, but not the law.
  • Please don't make referrals 30 miles away when there are closer clinics.
  • Don't get made when CPS comes to see the child for which you reported and then asks you to give your assessment of the child's condition or referrals for that child.
  • When I ask for medical records and you say that you will fax them to me the next day. I expect them faxed, not mailed a week later.
  • Please don't let your residents see CPS kids, they are too traumatized and too complicated to be seen by a resident and an attending in back-to-back appointments.
  • Residents in training, please state your name several times.
That's all I have for now doctors. Remember that just because you have the power to diagnose and prescribe, that doesn't me you have more knowledge than anyone else.

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