Even Specialists Need to be Primary Care Doctors on Occasion

My husband received a phone call from a friend in a panic. She was in a urologist’s waiting room with her son. The son is his early 20’s and previously healthy, was seen in the emergency room the night before with severe flank pain. The ER physician originally thought the young man had a kidney stone although there was no blood in his urine (a classic sign of a kidney stone). While in the ER he develops numbness in his groin and difficulty standing on his right leg. He is also having difficulty urinating. After the family relates this change in condition and since the kidney cat scan(CT) is negative, a CT of the head is performed. It is also negative. At this point the ER doctor shrugs about the difficulty standing and the young emergencyman is given an appointment for a urologist the next day. In hearing the story my husband and I agree—the problem is in the spine, not his urinary tract but the urologist is in the best position to get him further assistance from the appropriate doctor. I reassure the mother. Fifteen minutes later there is another phone call from her. They are in the car (15 minutes later?) with a prescription for his prostate and an admonishment to call their primary care doctor to get the young man in to a neurosurgeon. It is at this point that I lose it. Maybe things have changed since I (and this urologist) went to medical school, but difficulty urinating or defecating from a neurologic problem was taught as a neurologic urgency. The specialist has now put yet another physician in the way of this young man getting an appropriate diagnosis with treatment.

I’ve already texted the patient’s symptoms to my first year medical student daughter who quickly makes the diagnosis of caudal equina syndrome. I’m amazed, not that my daughter made the diagnosis, but that the urologist couldn’t or wouldn’t. I am furious that the patient is made to see another unnecessary physician and that the urologist is unable or unwilling to call another doctor. Are we really that busy? Worried about the young man’s inability to void, I make a quick phone call to a neurosurgeon who agrees to see him within the next hour. The young man receives his MRI in the morning and a preliminary diagnosis of cauda equina syndrome is made. Within 24 hours he is getting the treatment he needs.

This is a classic example of how fragmented our healthcare system has become, when physicians can’t think beyond the silo specialties they’ve created. Sometimes I have to think like a specialist and sometimes the specialist has to think like a primary care doc. That’s why we all attended four years of medical school and studied other organ systems besides the one we might primarily treat. And at all times, we need to think of the patient and the best care for him, not the care most convenient for the physician.

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