Posted by: notdeaddinosaur | May 3, 2013

Referral-go-round

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:

  1. 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:
  2. Diagnose eczema, and tell him to start by trying moisturizers
  3. 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)
  4. Realize that the cough is probably coming from the GERD and tell him to wait and see if it persists after treating his heartburn
  5. 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.
  6. Diagnose BPH and give him prescriptions for generic finasteride and flomax, and
  7. 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.

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Responses

  1. The problem that we’re having, finding a good family doctor that will really listen and not just send us to specialists.

  2. You should add the cost to your (the family doctor) office for opening, reading, filing, and storing all those reports from the specialists. And way too often, I just get the note from the initial consult, without the results of lab, Xray, pulmonary testing, etc.

  3. But you are “Just” the family doctor! [the implication being you are too dumb or lazy to be a “specialist”]

    I used to get this all the time — “You’re too bright to be “just” a nurse! You should be a doctor!” I never wanted to be a doctor. Nurses aren’t diluted doctors, they have an entirely different approach to the patient.

  4. Then why does my “primary care doctor” send me to a specialist every time I go to his office? I’ve been seeing this internist for two years and he’s never treated me once for anything! It’s always, “you need a cardiologist, (or a gastroenterologist, or a pulmonologist, etc.)”? He has wasted more of my money on unnecessary consultations, tests, ER evaluations, etc. Granted I am am falling apart (my meds and disease list would make you sick just looking at it) but still! 😦

  5. I’ve had three flavours of family doctor (I’ve had far too many over the years due to moving and a series of half a dozen who either lost their licenses or went on permanent maternity leave…):

    1. The kind described in this post – useful, but few and far between.
    2. The kind who says “one issue per visit” – usually not a problem if you’re only going in for the occasional acute issue, but for a complex patient like the one described here, it can take months (because one issue per visit, with follow ups for each issue…).
    3. The referral factory. Everything got referred if she could – my daughter’s head was disproportionately large, and even though she was developmentally advanced the doc referred her to a pediatrician!

  6. @Miss C: Ah, an internist. Not a board certified Family Physician (and not one that’s too chicken to see kids).

    Everyone: I get it. Docs like me are apparently few and far between. I’m sorry. Try paying primary care appropriately and quit denigrating us to med students the moment they express interest in what we do, and you’ll find more of us.

    Also: take our word that we know what we’re doing, and don’t second-guess us by going to all those specialists anyway even after we’ve told you that you don’t need to.

  7. The problem is in finding such a doctor. They are unfortunately not that numerous!

  8. And to expand on what anonymous said, the family doc gets paid jack for opening, reading and filing said reports. And then there’s the patients who’ve been on the net and Good Housekeeping (think “Take Charge of your Health”) and believe they need a specialist for every issue and feel that they’ve had poor care if they don’t get a referral. The specialists don’t respect us and the patients don’t either. And people wonder why they can’t find real family doctors. Take a long look at us folks, because family docs like dino (and me) won’t be around forever. Hope ya’ll like your “team centered medical homes” (what a crock) because that’s all you’ll have when we’re gone, since medical graduates now aren’t going to sign up for this kind of abuse and the vast majority are specializing. Don’t say we didn’t warn you.

  9. mamadoc, I would love to find one of this almost extinct species. Any primary care doctor that I have seen immediately starts with the complete battery of tests and then the referrals start. Pretty soon you’re seeing a whole platoon of docs!

  10. This is why I love my primary doc (and she is indeed a Board Certified Family Practice doc). 99% of my medical issues get addressed in her office. If she refers me to a specialist (which has happened 2 or 3 times in the 15 years we’ve been together) it’s because what’s going on is beyond her own expertise — and once the specialist figures out an appropriate treatment, I go back to HER, not the specialist, for followup.

  11. I saw so many family doctors before I went to the internist. They were WORSE. One time, I had pneumonia, and the family doctor I saw at the time gave me a different diagnosis every week: “You have a sinus infection” one week, “you have congestive heart failure” another week. My ENT ended up diagnosing the pneumonia and treating me. Also, I have had asthma for YEARS, had no idea I had it, and every family doctor I’ve ever seen told me it was bronchitis and gave me a cough syrup for it. When I finally got properly diagnosed (by the pulmonologist) he asked me why had I never treated my asthma, and I told him, “no one ever told me I had it, and I had no clue.” So no offense, Dr. Dino, but you are truly one in a million. (and I mean that in a good way) (Another family doctor I saw told me it was “perfectly normal” not to have a TSH level–mine tested out <0.01 several times–and again, my ENT ended up diagnosing my thyroid problem).

  12. Ditto to most of these comments. I live in a state with a major doctor shortage. It took a long time to find a doctor who was accepting patients. She turned out to be a referral fanatic. I would love, love, love to find a doctor who would tell me – “you have a rash? Let’s try this.”

    I have chronic medical problems with diverse and changing symptoms and I’m in perimenopause so I’m constantly wondering “is this my chronic problem? perimenopause? or something new?” Due to my doctor’s reluctance to actually TREAT me I am growing more and more hesitant to make an appointment and instead I’m surfing the internet to make my best guess as to whether I really need to go in or not. I need a new doctor!

  13. Bio: exactly!!

  14. I like and trust my family practitioner, but I have learned the hard way that sometimes he likes to order expensive tests. I complained of hip pain, so he took an X-ray, which led to his diagnosis of degenerative joint disease. He said I probably needed a hip replacement and referred me to a surgeon — but first he sent me for an MRI. Not knowing any better and being in fear about this new diagnosis, I went for the MRI. Over the next two years, I went to four surgeons who offer different options (laparoscopy, but my hip was too far gone for that; traditional hip replacement; hip resurfacing; and minimally invasive hip replacement). They all confirmed the need for hip replacement, but not one of these docs wanted to see the MRI. They wanted to see a digital X-ray. So I wasted hundreds of dollars on a co-pay for the useless MRI.

  15. As it has already been said by others – I would LOVE to see fewer specialists and have most of my treatment handled by a single doctor. I get frustrated with “maintenance” visits to specialists for problems that are currently managed. How many doctors do I really need and how do I know who to call when I am sick?

    My care is handled at a major medical center and I’m working with their patient relations dept to try and find and get into see a primary care doc who is comfortable actually managing a complex chronically ill patient. Not seeing any luck in this endeavor

  16. Aghhhhh, don’t you just love American health care. Everyone’s a winner except the patient’s bank accout. Couldn’t agree more… A good family physician / GP is worth their weight in gold

  17. I have been going to an internist for probably 20 years now and I’m a nurse. We’ve worked out a nice balance – gather some history and data in physical exam, discuss the most likely dx/rx plan, and start there. We are both comfortable with applying ‘tincture of time’ with a few drops of reassurance mixed in with information about what change or new symptom would need attention, and some encouragement for doing what i can with weight management, etc. I don’t want to get on the specialist merry go round, and he’s very value conscious and evidence based – so if he does send me to see a specialist, I know it’s necessary.
    He’s an early email adopter, and works in a practice owned by his hospital, if that makes a difference.
    My worry now – that as the hospitals are all forming alliances and ACOS and all that stuff, I will end up leaving him – his hospital is not that close to where I live, would be very hard to get there via public transit if i were too ill to drive. there are two networks available in my area that I drive PAST to get to him, workable for adult stuff, but won’t work for serious stuff or the constellation of services usually needed in geriatrics. and I don’t like those networks – very profit driven, big practices, test happy, and upcoding experts!
    As a nurse – my geriatric clients HATE the specialist routine, to the point where some have stopped medical care and just go to the ER when they think they should – not what health reform intended! And I won’t start on the reality that geriatric clients have a nearly impossible job getting anyone to look at their whole medical picture, much less the rest of the person beyond the diagnoses and meds. Wish we could clone you, Dr. Dino.

  18. I’m currently a Family Medicine resident and these are things that I see (and manage) in clinic routinely without specialist involvement (well, okay, maybe with a Psychiatrist…if my patient can get in to see them this year). Patient with a current problem list in the tens? Check! Med list in the dozens? Check! Large portion of patients that show up 15 minutes after their allotted 20-minute appointment time, require an interpreter, and expect to be seen immediately for their eight acute complaints (that have really been present and unchanged for several years)? Check! Check Check!

    After reading the post and comments, I do recognize that there are many physicians that do refer a lot, both FM and non-FM (yes, IM and Peds, I’m also looking at you!). As far as whether or not this is unnecessary, a large part is personal experience, knowledge, and style.

    Not to justify, but there are many reasons for referring to a specialist -sometimes medical, sometimes to make life less painful for the physician (you have to pick your battles). They include (but are certainly not limited to): the patient has little respect for family physicians and demands a referral to X specialist lest they file a complaint with the board (and they have done so in the past, have a current medical malpractice suit ongoing against an outisde physician, and are trying to covertly record the visit without informing you); the time-constraints of trying to do justice to eight completely unrelated (and one Psych-related) complaints in the limited time you have and the patient absolutely refuses to come back after you address the first three because they already waited five years to see a doctor about their problems; and some people have their own area of focus/expertise – one reason many people go into Family Medicine is so that they can tailor their practice to see parts of medicine that are of particular interest to them, whether it’s thyroids, women’s health or geriatrics.

    On top of all this, it is impossible to know everything about everything, much less possible to keep up with developments in every aspect of medicine/pediatrics/obstetrics/surgery/radiology/etc. As family physicians, we care for everyone – children, adolescents, adults, seniors, and really really really old people; men, women; pregnant women, non-pregnant women; and so forth. That’s why we have specialists.

    A large part of primary care is evaluating and treating people. Most of the time, we should be able to do this – and, assuming that the physician takes pride in the care they provide, this usually gets better with experience. For example, notdeaddinosaur has probably been doing this whole doctoring thing for longer than I’ve been alive! As a result, I would rather see her than try to diagnose myself. Sometimes, these things are also outside of our experiences. There are even subspecialists that dedicate their entire lives to a tiny niche and still see certain things a few times in their careers spanning decades. From a medical perspective, humans are not like cars – sure, we have to use heuristics (because “common things are common”), but every person is different and requires an individualized approach.

    As far as ordering expensive/unnecessary blood work and imaging, there probably is some factor of moneymaking for a select few. But, for the vast majority, it is probably (1) CYA (aka cover your a$$ aka defensive medicine aka order every test known to man so that in the event someone sues you. their attorney can’t say, “Mr. X presented to you with cough. In this survey study of n=2 published in Papua New Guinea in 1983 by a medical student, there is a clear link established between cough and colon cancer. Why did you fail to order a colonoscopy? My client requires damages in the amount of $250,000 because you negligently failed to order a colonscopy to work up his cough.”), (2) CYA (see (1)), or (3) the patient demands it and makes threats (see above).

    Oh, and while many people often get caught up in the money and complain about about how much you make because you’re a doctor and how expensive and difficult it is to see you (after all, we’re all loaded and driving BMWs from the time we were medical students, right?), the actual amount we get paid per standard visit is around $30. Before tax. With rates like that, you HAVE to be efficient or your practice will shut down pretty quickly. Sure, your bill might say that your visit cost $90. BUT, that’s about as accurate as the MSRP listed on Amazon.com for the latest non-Apple doohickey you bought. That new nose hair trimmer has an MSRP of $199.99? No one realistically charges and gets that amount…unless they’re a defense contractor (bazinga!). Medicine is one of the few fields where you perform a service, bill an organization (insurance), and pray you get paid even a fraction of what was billed.

    Again, my goal is not to rationalize/justify a very messed up system, but to provide another perspective. (I hope notdeaddinosaur doesn’t delete this…it took my entire Friday night off to write; that’s the funny thing about residency, it’s not that you miss having a life, it’s that you are at a complete loss about what to do when you have a few hours away from work).

  19. Holy code brown, that was a LONG post! (Sorry!)

  20. @FMResident: But sooooo well said. Thanks for the props.

  21. @notdeaddinosaur: Thanks 🙂 I actually just came across your site for the first time yesterday, You’re a very entertaining writer and much of what you write about definitely resonates with the things I see even in my limited experience as a resident.

    P.S. As of today your posts span 39 pages.

  22. Man, the one that makes me want to cry is when I have a somaticizing patient who goes to some specialist, who then sends her to another specialist, who then orders MRIs (yes, plural), and recommends another specialist. She has been hurt by being given dangerous medications and steroids (converted her to full blown diabetes) and yet no matter what I do, I can’t seem to put the brakes on it. (Seriously, neurology AND neuro-opthalmology referral from her rheumatologist when she shows up with Bell’s Palsy??? A head CT and – get this – a lumbar MRI.) In fact, the only reason I even see her after this circus is that one of them said, “You know, you really need a PCP.”


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