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Referring to an Orthopedist: When and Who?

When an athlete gets hurt there is only so much we can do for them prior to sending them to an orthopedist for further evaluation and imaging. Aside from gathering a solid history, doing a good evaluation and setting up a proper therapy program may not be enough to keep the athlete on the field. My question is: at what point during this whole process do you refer your athlete to the doctor?

Furthermore, there are a number of fantastic surgeons and clinicians in every area. What dictates who and where you refer to? It has been my experience that a local doctor gets a good deal of the business but what about the athlete that needs specialized care? Then what dictates who you refer to? What about your friend/family member? Are we keeping the best surgeons a well-kept secret?

Comments

  • Frank-
    That's a very good question the answer however is complex because there are many levels to consider.

    Severity of injury
    After we have done a proper evaluation and the Athletic Trainer has determined how severe the injury it is can determine the need for a referral. If the decision has been made to treat without referral tat is up to the discretion of the individual Athletic Trainer but if the symptoms are not diminishing than a referral needs to be made in the best interest of the athlete.

    Level of Athletic Training
    This plays a role because at the college and professional level the doctor will come in regularly so there isn't always a need for a referral because he's already going to come in but at high-school level a doctor is not as readily available.

    Insurance
    Everyone's health insurance isn't the best so parents may want to hold off on sending the athlete to see a doctor for financial reasons. There can also be restrictions on who the athlete can see based on insurance coverage.

    Availability of time
    Depending on what level you are at this will determine the amount of time you have to spend with an athlete. When time constraints prevent the athletic trainer from being able to properly progress their athlete it may be time to refer them do you may see them in the clinic.

    Availability of resources
    Sometimes the athlete may need access to a modality that you don't have at your disposal. This is when you have to make a referral so they can get the help they need to make a successful recovery

    Business
    This is something that isn't talked about nearly as much, healthcare is a business. As such certain companies refer to certain doctors or push Athletic Trainers to make referrals so they meet a "quota". So in some instances you may be forced to make a referral even if it is unnecessary.

    Once again that is a very loaded question where there is no singular answer.
    Audric Warren MS, ATC, CAFS, NASM-PES, NASM-CES
  • Hi Frank,
    Great question. Over the years I have worked to create relationships with many docs in the area. I am able to call a sports medicine physician or ortho for a consult at anytime and usually may get my athletes in within a day or two. If the athlete is in need of a different specialist I typically ask my supervising physician who is an ortho I have a great relationship with to help me out for referrals in town.

    Creating relationships is key. The physicians I use trust my opinion and know when I ask for a consult, it is typically for good reason.

    -Anna
    Anna J. Hartman MS, ATC, CSCS, PMA-CPT
    www.movementrev.com
  • Audric/Anna,

    Both great responses and you both bring up some key points. First, I want to touch on Anna's statement that creating relationships is key. I do not think there is another athletic trainer out there that would have a valid argument against it. The relationships we build with out athletes and the physicians we refer to are paramount to our success. As a young professional or one that is inexperienced, it is difficult to differentiate between the doctors that want our business and the doctors that truly can be an asset professionally and intellectually. ATs are constantly adapting to our environments since injuries and treatments are ever evolving. We need a physician that we can rely on not only for our athletes and maintain the trust we have established, but also one we can seek out for advice or just to bounce ideas off of. In the college setting, I had a physician who was not only a tremendous mentor but someone who was very hands on with the athletes and ATs on staff (he shared our office with us) and was sports medicine oriented although he was not an orthopedic surgeon. So when I got to the high school setting, I had a team physician who was a pediatrician that was essentially there for legal reasons. That said, these two doctors were on either end of the spectrum which would lead to a no-brainer-situation in who I would refer to given the choice.

    As for orthopedic surgeon referrals, each setting brought about its own challenges. Both settings had the athletes that "wanted to see their family doctor" because it was either a family friend or someone who they had been seeing for years. At the college setting, as Audric mentioned, our team orthos would make a weekly trip to the athletic training room to see anyone and treat our walking-wounded. At the high school level, it is very difficult to get an appointment for your athlete within reason. Additionally, if the orthos are not at the football/collision sport games then it is difficult to build that relationship and you are stuck in a rock and a hard place. And I do not know many ATs that are making rounds to doctors offices to check in with them and ask why we should refer to that doctor.

    Audric brought up the fact that healthcare is a business. Although I completely agree with that statement, I hate to look at it that way. Mostly because I got into Athletic Training to satisfy two different desires of mine: be around athletes and be an allied health professional. I didn't go to school to work in business nor was it even an thought of mine; but as I mentioned before, healthcare is ever evolving and right now it appears to be more of a business than anything else. Although referring to a specific orthopedic is necessary at some point, who we refer to is essentially who we are giving our business to. Insurances play a large role as to who gets into where and which doctors we refer to but at some point we need to refer to the best of the best. Regardless of insurance and cost, a high school player who needs Tommy John is going to see one of the best in the area. For example, there are two renowned surgeons in NYC who perform UCL reconstructions: Dr. Christopher Ahmad and Dr. David Altchek. One of them is the Yankees team doc (Ahmad) and the other is the Mets team doc (Altchek). Now regardless of which subway train you prefer or shade of blue is your favorite, there are going to be reasons why you choose to refer to Ahmad vs Altchek. They're in the same business, and they both supply something (surgery) that your athlete demands. As athletic trainers, unless we spend the day with each of them, we won't see their bedside manner and for the people who are doing the referring it may not make a difference; but to the patient and their family it means the world. So what sets these two men apart? Who gets your referral? This may seem like an extreme case, but if you live within reason to NYC it may not sound so farfetched considering they are the best around.

    Another point Audric brought up is that there are many tangibles related to who and when we refer and again, I couldn't agree more. Nonetheless, there comes a time that even the person who is limited by their insurance will pull out all the stops and go see the best of the best. How do we make an honest referral with limited resources?
  • Frank,

    Audric and Anna have made some very good points of which I concur. I would also like to give you a few additional things to consider. Listen, listen, listen. Regardless of your setting, your available resources, or your skill level, an injury will respond to your treatment in one of three ways. It will improve, it will get worse, or it will stay the same. If it does either of the latter two, you refer on. This is not a knock to your abilities, rather a testament to them. It is your job to treat what you can within your practice act and refer what you cannot. I prefaced this by saying listen. Listen to your athlete as you treat them and they will tell you what to do. If they do not think they are getting better or the parent expresses this, send them on. I realize that sometimes you know they are getting better and they just need a few more days to turn the corner, but they may not know that. You may know the doctor will just say the same thing as you have told them. Exactly! Whether the doctor comes to the training room once a week or the athlete goes to the physician's office, it doesn't matter. When the athlete comes back after consulting with the physician who concurs with your evaluation, the athlete will say you were right. The athlete's opinion of you and your judgement just went through the roof in their mind or their parent's mind or the coach's mind. You don't have to say, "I told you so." Anna said it is about relationships and that is what you are doing. I always tell new AT's that the first year you are somewhere you are establishing relationships with the coach and they will test whether you just want to pull all their athletes off the field. The second year the relationship is with the athlete because most will have suffered some sort of injury within two years and they will then come to you first. The third year is with the parents. When their son or daughter comes home complaining about an injury, they will tell them to go tell the trainer before rushing off to the ER or pediatrician.

    Your second question was about who to send them to. Again it is relationships and listening. Audric talked about resources, insurance, family doctors, friends, and business. All are correct. When someone asks who and why I send someone someplace, I don't have a hard script. Understand you are the person or gatekeeper with hundreds of possible referrals. You are the one in control. Doctors don't make money without referrals. The same goes for physical therapists. You don't have to go around to ask them why you should refer to them, they should be coming to you. Just because they give $500 to put a banner up doesn't make them your team doc with exclusive referral rights. I also am blessed with many outstanding physicians and surgeons. I tell them what I expect from them and it isn't much. I want communication. All will tell you they will see your athletes within 24-48 hours and most will follow through. How many will call you on the same day they saw your athlete and give you a status report or MRI results? That is what I expect. Yes the athlete will give me a script from the doctor with general notes for therapy parameters. However, athletes are different from the general population. Can the athlete still shoot free throws, can they still work in the weight room, what about adding aquatic therapy? I want to discuss these things with the doctor over the phone. Do you have their cell phone and their nurse's? When I call with a question will they answer or call back in between patients? I hate it when the physician's nurse calls you at 4:55pm (when you are in the middle of treatments or a game) with a response to an inquiry and you try to call the office back two minutes later with a follow up question and it goes to the after hours answering service. I want to be able to call the doctor at home when I am at an away basketball game at 9:00pm on a Friday and set the appointment for Monday morning. Doing that will blow a parent's mind away. Finally, your reputation will be aligned with the doctor's. I will send an athlete and family to a particular doctor because of the personality of the doc and the characteristics of the athlete/parents. Let me give a brief example. If a parent asks a lot of questions regarding their child's injury, don't send them to a doc who has a poor bedside manner and doesn't spend more than 5 minutes with a patient. Find a doc who likes to explain things or at least prep the doc ahead of time. If you have a situation where the athlete or parent doesn't do well with details and just wants the bottom line, you can send them to the all business, no talk doc. If the parents don't like the doctor's personality, that will carry over to their opinion of you. The reverse is also true. Listen, listen, listen!
  • Anyone here know of any physician extender positions in New York City area? I am looking for a job.
  • I have a suggestion. It does take some time, but in preseason have a form that asks for info on who to refer to in case of injury considering HMO guidelines. It helps make referral much more swift. Keep your list of docs handy and communicate with them regularly!
  • Thank you Robert for the suggestion!
    It seems easy but with our busy schedules we sometimes get overwhelmed and forget to do the basics.
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