Page 24

BulletinNovDec2017

Reflections Wearing Two Hats: Reflections of a Practicing Utilization Review Physician Steven Barna, MD sbarna@floridaortho.com After completing my residency in anesthesiology and a fellowship in in-terventional pain medicine, I spent the first few years in practice dividing my time equally between the two special-ties. Ultimately, I transitioned to a full time interventional pain practice. One valuable lesson I learned during that early part of my career, balancing these two really very different clinical hats, was the importance of having perspective. Simply put, the per-spective I obtained was as simple as being on either side of the operating room surgical drape. When in the role of anesthe-siologist, I had the important job to not only make the patient comfortable and not move during the surgery, but the overrid-ing part of my job was to ensure the patient stayed alive and safe--whether for a life-threatening trauma or an elective knee arthroscopy. Despite deeply knowing the importance of my role as an anesthesiologist, or the now more descriptive “peri-operative physician,” I somehow felt left out and alone at times on my side of the surgical drape. The attending surgeon, surgi-cal resident, surgical tech, and operating room circulating nurse were nearly totally focused on the surgical side of the drape, and for the most part, rightfully so. At times, it felt like their focus on my side of the surgical drape was only if the patient moved unexpectedly (while of course still under deep anesthesia), or the table height needed to be adjusted--trivial things relative to being the perioperative guardian of this patient’s life. In contrast, as an attending interventional pain physician I now stood on the surgical side of the drape, assisted by my own interventional pain fellow, surgical tech and circulating nurse. On the other side of the drape stood an anesthesiologist, who just the day before may have given me a lunch break when I was providing anesthesia that day. After putting on my surgi-cal gown and adjusting the operating room lights overhead, I would then ask for the scalpel to make the first incision whether it is for a spinal cord stimulator implantation or a kyphoplasty. It was only after the very first time in my role as “surgeon” on that side of the drape and every single time since, that I realized how misguided I was when on the anesthesia side of the drape. When I was in the role of “surgeon,” I, along with everyone else on my side of the drape, was immersed and in the moment to ensure that the surgery went well--safely, technically, and effi-ciently. Glancing a concerned look at the anesthesiologist if the patient bucked, or asking to raise the table to obtain a better lateral view on fluoroscopy were just simple requests in order to continue my intense focus on the surgical task at hand. On my surgical side of the drape, as far as I was concerned, we were all one team, with a singular mission to ensure a technically suc-cessful surgery, as well as the patient’s safety and well-being. There was no need for Freudian psychoanalysis of surgeon or anesthesiologist. Simply put, we were vital in our own ways and on the same team, where attention to one’s ego on either side of the drape provided no added benefit to the patient, for whom we were all really there to help. As a part-time utilization review physician for the past few years, I have peer-to-peer telephone discussions daily with fel-low physicians around the country regarding diagnostic and therapeutic requests for their workers compensation patients. This insight and perspective I’ve gained by being on both sides of the peer-to-peer process align with my experience on both sides of the surgical drape. While we as practicing physicians generally feel that these peer-to-peer requests are ridiculous and unabashed waste of our valuable time, I can candidly say that in most cases, the utilization review is necessary. Typically, a re-viewing nurse presents me the pertinent provider clinical notes, a summary of the case, the relevant insurance provider clini-cal policy, and what specific documentation is either unclear or deficient, thus preventing approval of the diagnostic or thera-peutic request. A small portion of these cases are never going to be approved because the requests are simply outrageous. For example, I’ve seen a request for installation and maintenance of a personal home hot tub for someone with low back pain. Another outrageous recurring example was a request for an un-proven non-FDA approved topical compound cream for knee pain at $1,000/month for years to come. The vast majority of these requests really come down to ei-ther clinically inappropriate care or lack of documentation for clinically appropriate care. An example of clinically inappropri-ate care is prescribing an nsaid for nonspecific low back pain for years with the concomitant cardiovascular, renal, and gastro-intestinal risks over time. An example of lack of documenta-tion is ordering a steroid injection of the knee without noting pertinent x-ray, physical exam findings, or conservative care already attempted. In all cases, I am up front with the request-ing physician and let that provider know exactly what we need (continued) 24 HCMA BULLETIN, Vol 63, No. 4 – November/December 2017


BulletinNovDec2017
To see the actual publication please follow the link above