Specialist versus Primary Care

This morning a patient calls the office stating that his surgeon, who has been treating him for an abdominal wound that is still not closed, told him at his followup appointment that he needs to see a wound care specialist. The patient was instructed to call his primary care physician (PCP) and tell me to set that referral up for him. WHAT?!?!?!?! A few hours later my 28-year-old new patient tells me the orthopedist she saw this morning told her she had a kneecap problem, take Advil, stop running and get an MRI. When the patient explained that she wants to be an Air Force nurse and will have to go through boot camp, it was reiterated that she needs to stop running and maybe she broke her kneecap, so she should wait for the MRI. She has NOT had an injury and  BOTH knees hurt. She has noticed that after exercise her knees feel better. I spent five minutes explaining what patellofemoral syndrome is and suggested that she delay the MRI and see what routine quadriceps exercises do to improve her pain. I suggested substituting bike riding for the running but if running doesn’t seem to bother them, then she might just cut back on that and substitute biking. WHAT?!?!?!?!

This is not an uncommon experience for me. The first episode made my blood boil. AT LEAST once per week, many times more often, specialists tell patients that I will set up appointments, refill medications or interpret the tests that THEY did on a patient. If this occurs following a phone call to me BY THE PHYSICIAN HIMSELF, this is appropriate. But making the patient the intermediary is unfair to the patient, boldly rude to me and in a patient-centered environment, absolutely terrible care.

It is ironic to me that the individual who makes the least amount of money per patient in the doctor hierarchy, is more and more forced into the position of spending more time with patients to make up for, or frequently do, the job of the specialist. I love taking care of patients but I will NOT be used and abused by individuals who, whether they recognize it or not, are treating me like some sort of glorified physician-extender. 

Now I realize that the counter-reaction from the specialists is going to be that we, the first-line doctors, are sending patients to them without adequately working up the problem thus earning the label of “lazy intellect” from the specialist. I truly try not to do that. After all, that is the most interesting part of being a physician, the detective aspect of putting symptoms and tests together to try to make a diagnosis. That is one of the reasons I chose primary care. And most specialists are not egregiously forgetting their own responsibilities. But as it gets harder and harder to navigate the insurance traps and pharmacy coverage nightmares, as specialists accounts receivables fall and they try to increase their patient load to keep up (PCP’s gave up on that a long time ago, we just decided to become employed in droves), it gets easier to tell the patient to call me with the expectation that I’ll take care of it.

“The good physician treats the disease; the great physician treats the patient who has the disease.” William Osler. I would add to that “The good physician sends written communication to colleagues. The great physician picks up the phone to communicate with colleagues.”

OH, and while I’m on the subject of phone communication–does ANY specialist out there remember the common courtesy rules of making phone calls? If YOU want to talk to me, then YOU call me. You do not have your nurse call me and leave me sitting on the phone fuming while I await your presence. Why in the world do you think your time is more important than mine? I mean besides the fact that you get paid thousands of dollars more than I do. Your mother would be ashamed!

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