Guy goes to see a doctor for a skin rash, stomach ache, cough, knee pain, trouble peeing, and is found to have high blood pressure. He’s seen at his team-based medical home and sent to a dermatologist for the rash, gastroenterologist for the belly pain, pulmonologist for the cough, orthopedist for the knee, urologist for the urinary problem, and a cardiologist for the high blood pressure.
The dermatologist diagnoses eczema, gives him a prescription for a steroid cream, and tells him to follow up with GI, Pulmonary, Ortho, Uro, and Cardiology.
The gastroenterologist orders blood tests, a CT, does an EGD and colonoscopy, diagnoses him with GERD, gives him a prescription for a PPI, and tells him to follow up with Derm, Pulmonary, Ortho, Uro, and Cardiology.
The pulmonologist orders a chest x-ray and PFTs before even seeing him, then diagnoses cough-variant asthma and gives him a prescription for an albuterol inhaler, Advair, and singulair, then tells him to be sure to follow up with Derm, GI, Ortho, Uro, and Cardiology.
The orthopedist orders x-rays and an MRI of the knee (again before seeing him), diagnoses osteoarthritis, and gives him a prescription for Mobic and a pamphlet about knee replacement, telling him to think about it, but also to follow up with Derm, GI, Pulmonary, Uro, and cardiology.
The urologist orders a PSA (because he’s breathing; the urologist, that is), does a rectal exam, diagnoses BPH, gives him prescriptions for Proscar and Urotraxal, and tells him to follow up with Derm, GI, Pulmonary, Ortho, and Cardiology.
The cardiologist diagnoses him with hypertension, sends him for a nuclear stress test and echocardiogram, then starts him on Exforge and tells him to be sure and follow up with Derm, GI, Pulmonary, Ortho, and Uro.
Each of these doctors also brings him back for a checkup annually for the rest of his life.
Same guy comes to see me. I proceed to:
- Take a complete history, do a thorough physical exam, and order some basic blood work (including a PSA in this case) which allows me to:
- Diagnose eczema, and tell him to start by trying moisturizers
- Suspect that his stomachache is actually heartburn, tell him to consume less alcohol, caffeine, and tobacco, lose some weight, and try some antacids first (then OTC H-2 blockers, ie first generation anti-acid meds)
- Realize that the cough is probably coming from the GERD and tell him to wait and see if it persists after treating his heartburn
- Diagnose osteoarthritis and tell him to start by trying two extra-strength Tylenol (1 gram total) four times a day, and that losing weight will help his knee as well as his GERD.
- Diagnose BPH and give him prescriptions for generic finasteride and flomax, and
- Tell him to come back and re-check his blood pressure, as the diagnosis of Hypertension requires that elevated readings be found on three separate occasions.
Total cost for the first: Multiple thousands of dollars.
Cost for my care: a few hundred dollars at most.
Total time available in the specialty appointment books for patients who actually need to see them: you do the math.
Why on earth do people voluntarily board this ridiculous runaway referral-go-round instead of seeing a good family doctor (and paying us appropriately) first?
I’ll never know.