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.
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.