advice on situation with PCP

[Attending1985]

I work in a large hospital system so interact with a lot of PCPs. Most are fine. In the past I did have a patient tell me that their PCP criticized a decision that I had made regarding a medication change. The patient was offended by the comment and found it to be unprofessional. So much so that the patient fired this person as their PCP and went to another health system for primary care. At the time, I didn't take any action against this provider.
I have a patient that the same PCP referred to me who is a 70 year old women with chronic depression and anxiety who's in an emotionally abusive relationship which, imo, is the reason why she hasn't been able to improve over the years. I have a good relationship with this patient and we've been working well together. She remains in the relationship and has made some small gains but I continue to feel her relationship is a barrier to significant improvement.
When she first referred me this patient she told me that she thinks she has untreated ADHD and this the reason why her self esteem is so low. I told her that I disagreed and I felt that her low self esteem was secondary to a longstanding abusive relationship. Any cognitive impairment that she had I felt was due to chronic use of Klonopin which I am slowly weaning her from and her executive function is improving.
Recently her PCP reached out to her and asked her how she was doing. The patient said she was continuing to struggle and her PCP said she wanted to send her a medication to start without seeing her (I'm assuming stimulant). The patient said I think you should talk to my psychiatrist first. The PCP said I already talked to her and she's unwilling to try this medication. The patient said she would have to talk to her in person and scheduled an appointment.
I would consider this to be a pattern of unprofessional behavior. I don't expect everyone to agree with me but to talk poorly of me to my patients, then refer me a patient and contact her unsolicited to interfere with treatment without contacting me first is just not right. I'm wondering how other people would address.

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[mistafab]

I work in a large hospital system so interact with a lot of PCPs. Most are fine. In the past I did have a patient tell me that their PCP criticized a decision that I had made regarding a medication change. The patient was offended by the comment and found it to be unprofessional. So much so that the patient fired this person as their PCP and went to another health system for primary care. At the time, I didn't take any action against this provider.
I have a patient that the same PCP referred to me who is a 70 year old women with chronic depression and anxiety who's in an emotionally abusive relationship which, imo, is the reason why she hasn't been able to improve over the years. I have a good relationship with this patient and we've been working well together. She remains in the relationship and has made some small gains but I continue to feel her relationship is a barrier to significant improvement.
When she first referred me this patient she told me that she thinks she has untreated ADHD and this the reason why her self esteem is so low. I told her that I disagreed and I felt that her low self esteem was secondary to a longstanding abusive relationship. Any cognitive impairment that she had I felt was due to chronic use of Klonopin which I am slowly weaning her from and her executive function is improving.
Recently her PCP reached out to her and asked her how she was doing. The patient said she was continuing to struggle and her PCP said she wanted to send her a medication to start without seeing her (I'm assuming stimulant). The patient said I think you should talk to my psychiatrist first. The PCP said I already talked to her and she's unwilling to try this medication. The patient said she would have to talk to her in person and scheduled an appointment.
I would consider this to be a pattern of unprofessional behavior. I don't expect everyone to agree with me but to talk poorly of me to my patients, then refer me a patient and contact her unsolicited to interfere with treatment without contacting me first is just not right. I'm wondering how other people would address.

Tough spot to be in. You’re doing a good job of keeping things to yourself. You can’t control the other provider, and you can’t know exactly what is being said between this provider and your patients.

You’ve got a lot of options. You can always call the pcp directly and get on the same page. If reaching out doesn’t yield good results, you can make it clear to patients that you’ll only prescribe in cases where you have full control of psych meds. It is dangerous waters to have multiple hands in the pot, especially with controlled subs. Not the patient’s fault, but you need to be able to delineate turf when multiple providers are involved.

Last, it’s poor form for a doctor to criticize another doctor to a patient. I don’t recommend that. However asking around to other psych docs or pcps in the area/system may reveal that this doc is frequently overstepping their lane. May not directly help the situation, but it might make you feel better - and perhaps as a group people can bring this up in a more formal way (inside your big box shop).

No way it’s happening to just you. These type of docs tend to build notoriety rather quickly.

 

[TexasPhysician]

First I’d try to work this out interpersonally with the PCP.

If that doesn’t resolve the issue, I’d have an honest discussion with the patient that the 2 of you have different goals. Having 2 physicians with contradicting goals isn’t a recipe for success. The patient can consider a second opinion with another psychiatrist or a second opinion on another PCP. While not personal, you’ll be referring the patient back to the PCP to manage her mental health ongoing if electing to continue with this PCP.

This becomes a medicolegal issue if not resolved. The PCP is blaming you and other family may hear this. If there is a bad result, the family could be tainted to believe you were the problem. It’s also bad medicine to keep pushing and pulling the patient in different directions.

I do this to a degree when PCP’s decide to start jumping in, whether they have knowledge of me or not. I’ve been working on a patient’s sleep for some time. Just yesterday a patient told me their PCP started Ambien and it was partially effective. I advised them that having 2 doctors manage the same issue in different ways isn’t safe. I advised them to manage their sleep concerns with their PCP ongoing.

My opinion is that clinicians should either work cooperatively together or stay in their lanes. Once we start stepping on someone’s feet, it is time to back off.

 

[comp1]

I get it here, but I just really detest the term unprofessional. Grates on me. The OP needs to reach out to the PCP and get on the same page. Set up a scheduled meeting time, as annoying as that is. Communicating through a patient, particularly a substance dependent patient, is just about the worst possible way of communicating. That is the main source of the problem. This is why I much prefer integrated health systems where communication is just a click and direct message away. Also...don't hesitate to sign off on this patient and return them to the PCP if the PCP now feels comfortable managing the patient's situation. That's safer than working at cross purposes.

 

[Attending1985]

so I just saw this patient and she asked me about the conversation I had with her pcp. I said I haven’t spoken to your pcp in a long time. She was very confused and slightly upset. I shared with her our initial conversation about ADHD and stimulant treatment and said we had different opinions. Will be interesting to see how it goes when she meets with her pcp. If she puts her on the stimulant I will defer her treatment back to her pcp.

 

[Attending1985]

I get it here, but I just really detest the term unprofessional. Grates on me. The OP needs to reach out to the PCP and get on the same page. Set up a scheduled meeting time, as annoying as that is. Communicating through a patient, particularly a substance dependent patient, is just about the worst possible way of communicating. That is the main source of the problem. This is why I much prefer integrated health systems where communication is just a click and direct message away. Also...don't hesitate to sign off on this patient and return them to the PCP if the PCP now feels comfortable managing the patient's situation. That's safer than working at cross purposes.

I am in an integrated health system. That’s how I was able to see the message.

 

[comp1]

If you're in a system, send this PCP a DM and ask directly what is going on and what exactly they want to do going forward.

 

[J ROD]

I would gently remind the PCP that they referred the patient to you. If they do not agree with your actions, then they need not to refer patients to you and handle the issue themselves. If you have enough "juice" within your organization, you could also refuse referrals from that PCP. I have refused to "take over" benzodiazepines from PCP after they run it up and then refer to psychiatry for anxiety and then say they are not able to refill to patients anymore. I remind them they need to refer to me sooner before they created a "benzo monster". They need to manage their own mess.

 

[allantois]

Happens all the time. You could write in your note patient doesn’t meet criteria for ADHD and sent it to PCP..