Posted by: notdeaddinosaur | June 9, 2011

Once a Specialist’s Patient, Always a Specialist’s Patient

Guy in his late 50s with a mass on his kidney; turns out to be benign, which can’t be figured until it’s removed. Urologist does a lovely job of removing the kidney; everything goes swimmingly; guy makes an uneventful recovery; all is well. What’s next?

“I have asked the patient to return in one year with a PSA,” says the urologist’s letter.

Huh?

What the hell does a PSA have to do with the kidneys? (Hint: nothing.) Why does a guy with no lower urinary tract symptoms — with no symptoms at all, now that his kidney mass is gone (though technically, he didn’t have any symptoms with that either) — have to go back to the urologist next year, and presumably every year until his death, with an annual PSA?

How about this one: woman in her 30s with sharp, right-sided chest pain who insists on seeing a cardiologist; full workup (EKG, nuclear stress test, 2D echocardiogram, holter monitor — none of which are actually indicated by the history and physical) completely negative. Blood tests show normal cholesterol and blood sugar. Letter from cardiologist says:

“No evidence of coronary artery disease.”

Cool. But then there’s this:

“I would like to see her back in one year for a checkup.”

What the hell for?

It’s all part of mission creep on the part of specialty medicine. Why settle for just taking care of the problem at hand, when you can keep filling up your appointment book on an ongoing basis? Hey, fill out the proper forms and you can probably qualify as a “Medical Home,” something that’s supposed to be the newest incarnation of Family Practice. News flash, partialists: forming a longitudinal relationship with one tiny part of a patient’s body does not constitute primary care.

The “annual checkup” is becoming increasingly fragmented. Everyone wants their regular skin check at the dermatologist. Between those and same day appointments for Botox, it’s no wonder my patient with a suspicious mole has to wait six weeks to be seen. No one but a urologist is qualified to stick an annual finger up your ass. Gynecologists, trained as surgeons, provide “primary care” for women — ignoring new guidelines showing no benefit from annual pelvic exams and supporting far fewer paps than they’re accustomed to doing. Cardiologists insist on seeing patients with controlled hypetension back every year (with EKG, echo, and stress tests, of course). Migraneurs have to see the neurologist every year because, well, the neurologist wants to see them. Controlled asthma? Pulmonology and PFTs annually.

Hello? My job. I can do it quite well, thank you; less expensively than you to boot, Dr. Specialist.

I never thought I’d be praising the surgeons and orthopods, but they’re the only ones left who actually “discharge” patients after an episode of care. Healed fracture? Hit the street. Recovered from the operation (once the global surgical period is over)? Sayonara, buddy. (Except for boobs. Once a woman has had the slightest abnormality in her mammogram, only a surgeon is qualified to do a clinical breast exam on her; annually, of course.)

Want a realistic approach to curbing the meteoric rise in medical costs? Call off the specialists after they’ve taken care of an acute condition. Get them to relinquish patients back into my care — with parameters for monitoring — and let me do my job. (Introduce payment for “global” periods of care, like in surgery?) They’ll probably find themselves pleasantly surprised at the flexibility in their schedules to see new patients who need them urgently — which will actually make me more likely to want to refer other patients to them. Everybody wins.

 

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Responses

  1. As a patient, I’m frustrated by the specialist creep as well. I recently had a kidney stone, but before we could treat that, my primary care doctor and the urologist required that I have a MRI and consult my orthopedic surgeon. Why? Lumbar spine fusion a couple of years ago. The blood in my urine, the pain worse than labor, the spasms in my kidney….yeah, those just *might* be a problem with a perfectly healed fusion. Orthopod rolled his eyes at me, showed me how great my MRI looked and said to come back in 2-3 years. Oh, and go to back to my primary care doc to get treated for the kidney stone.

  2. For all my frustration at the Australian government trying ruin the last 20 years of my life a GP here (after 25 years already), that would drive me out of primary care altogether. Do your partialists have so little to do that this is even feasible?

  3. I thought I was supposed to see a dermatologist annually for my skin check, but she told me my internist could do it. But my retina specialist, EP cardiologist, and gynecologic oncologist are never going to let me go.

  4. It’s readily explainable in just six words: “because they can bill for it.”

  5. I will say that when I saw a cardiologist a few years ago for a possible heart problem, at my last visit (following several tests) he said, ” You have no heart problems, you are too young to need a cardiologist (45 at the time), and I don’t need to see you until you do have heart problems.” Surprised the heck out of me!

  6. My area constantly has articles about how there is a shortage of specialists, yet I find the same difficulty. If a patient has an elevated PSA and negative biopsy, why can’t I manage the PSA? If a patient has a negative chest pain workup in the outpatient setting or hospital, why can’t I take of the hypertension? Many specialists like to claim to be busy, but they hold on to the patients for potential future procedures. That same negative prostate or chest pain workup may represent another biopsy in a few years or another stress test in a few years. Having the patient maintain the relationship with the specialists is a costly way to make sure the same specialists gets to do and bill for the procedure. My area has general surgeons who won’t release the patient for five years after a hemicholectomy but with the patient seeing an oncologist. Orthopedics who replace the one knee but want the patient to get injections annually on the other knee. Neurosurgeons who keep the patient to give pain meds 2-3 times a year. What is really difficult is when the patient is admitted to the hospital and the specialists come in droves from the ER calls to see the patient. In the end, I often do not have a unique diagnosis to bill on the Medicare patients.

  7. This came up in conversation with a friend of mine yesterday. A few months ago he had his thyroid removed. As part of his treatment he was placed on Synthroid by the endocrinologist and discharged back to his PCP. Recently he has had unexplained weight gain and sought out his PCP. Who referred him back to the Endocrinologist for some reason.

    Should not a PCP be able to manage this medication change?

  8. When a specialist says, “Follow up with me in a year,” I’ve always interpreted it as, “Unless something’s wrong, you don’t need me anymore, but if I say that I don’t want or need to see you again, that sounds rude and makes me seem unavailable and unconcerned about your long-term health.”

    It’s not like they ever call a year later reminding me to make an appointment.

  9. Sorry, but this has to be laid at the feet of primary care just as much as the specialists, if not more so. I sure as heck don’t want to go to a specialist for a sore knee or my long term migraine medication. But virtually all “primary care physicians” I have encountered are unwilling or incapable of treating those conditions or prescribing those medications. It is difficult to get a year supply of blood pressure medication that I have prescribed for over a decade. The basic fact is that most of these doctors I have encountered are less useful that nurse practicioners. And that is insulting nurse practicioners.

    Put simply, most primary care doctors don’t seem to do primary care. If they are going to act as nurse practicioners and refer out care that is in their field of expertise, then replace them. That would save money too. Everybody seems to be concerned about a shortage of primary care doctors. Our system already has a fix for that.

    What we have is a shortage of GOOD primary care doctors. How you fix that to save the real money in a time frame spanning less than decades, I don’t know. I’ve finally found a good one. I suspect it is partly the organizational structure (good managed care).

  10. I would love to have the confidence that my PCP could manage my ‘issues’. She first diagnosed my SOB and ankle edema as fallen arches. A search on my own and a cardiologist out of network found a leaking aortic valve and Coarc.

    Annual followup with Cardio noticed my eGFR was not normal (looking back at different lab work, it hadn’t been normal for over a year @ PCP office)…now looking at a chronic kidney disease diagnosis.

    I’d love to have one person be able to monitor everything, but how do you go about finding a new PCP? I have 15 years of records with this clinic….

  11. How about ASKING your PCP if he/she can manage a condition, why or why not, etc.? Or ask the specialist WHY you need specialist followup instead of PCP monitoring? We all tend to repeat patterns, and when asked in a neutral way to explain their thinking, you may get a more considered response that has real information, or room to negotiate a plan! all this talk about ‘consumers’ being more responsible for their own health – well, it’s more than just ‘doing what the doctor tells you to do’.
    The other half of this issue is asking for referral to specialist when you don’t think your PCP is really paying attention or listening to what you report, or looking carefully at labs, etc. A system with an EMR that allows patients to see their own lab results, problem lists, etc. can be a place to start, if there are links to accurate information about what a test is for. (This bit is controversial, I’m sure, but this material can also be a way to generate questions that reveal what a patient is actually thinking/believing/worrying about.)
    My pet peeve is docs who insist on doing annual screenings on elders – really, what lady over 80 needs a mammogram or pelvic/Pap, unless she has a significant history or troublesome symptoms? Same w/ screening colonoscopies, or even followups in someone with dementia, etc. What about patients’ right to refuse a screening or treatment that has been explained to them in terms they can understand if they feel the risks/challenges are greater than any benefit?

  12. According to the American Board of Family Medicine’s website: “Board certification demonstrates a physician’s exceptional expertise in a particular specialty and/or subspecialty of medical practice.”

    Specialties range along the spectrum from those of “breadth” like family medicine, to those that focus on a particular age group or body organ. My specialty, pain management, has a focus that spans across organ systems and age groups but is limited in other ways. None of us is able to provide all of the care our patients need–so we must work together to do so.

    I would propose that the term “partialist” is pejorative and not particularly helpful in this discussion. In prior postings, I use the term “primary care specialist” to describe doctors who have completed specialty training in their field. I do a “complete” job within the area of my special”ist” expertise.

    With regard to “keeping patients” by setting up annual visits. My strategy is to keep patients by providing good care. This care extends to my relationship with their primary care specialist. I provide timely communication by phone or fax and make myself available for their phone calls with questions or concerns. My relationship with primary care specialists allows us to work together to provide “complete” care and also generates future referrals.

  13. I am happy to make recommendations or provide my requested consultation opinion and have the patient return back to his or her internist or family doctor. Generally I find that once a patient has seen me for something like OA or soft tissue pain, the next time they call their PCP with anything that hurts the answer in a phone call is “have the patient see their Rheumatologist.” In addition, I know of very few PCPs who do joint injections, so that is a lot of our repeat business. However, the interval is patient determined. Of course I’d like to regularly see patients I’m following who are on immunosuppressives, but that is not the majority of the practice.

  14. Here’s another perspective from the other side of the stethoscope: RFS provides such a good example here (pain management). After spending 10 years working in hospice palliative care (where people actually know how to address pain!) I am gobsmacked by the tragic ignorance and misinformation of most general practitioners about pain management. We couldn’t help but wonder why their patients had NOT been referred earlier to pain specialists?

    I agree that booking one-year follow-up appointments for what seem like flimsy appointment-filling reasons sounds suspect, but for many patients, it means that an expert will be checking in on us.

    I’ve had the same family doc for 35+ years, which is to say she knows me, my entire family and my lifestyle pretty well. After suffering debilitating depression following a massive heart attack (surprisingly common in as many as 65% of female MI survivors by the way, but according to Mayo Clinic cardiologists, accurately identified in barely 10%), I was forced to literally beg my family doc for a referral to a psychiatrist, but was put off repeatedly with a litany of excuses (“Wait list is too long” – “No good shrinks in this town” or this one – my fave: “Just try signing up for a really interesting night school class at the college!”) – based on what I can only deduce was her obvious distaste for that profession. Her alternative solution meanwhile: pull out her drug prescription pad. I had to finally put my foot down and INSIST on a psych referral (which, believe me, is terribly difficult to do when you’re in the throes of depression!).


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