Primary Care: Portal or Roadblock?

Hans Duvefelt, MD, discusses why many patients only want to see a specialist

Many Americans think they should be able to make an appointment with a specialist on their own and view the referral from a primary care provider as an unnecessary roadblock.

This "system" often doesn’t work because of the way medical specialties are divided up.

If belly pain is due to gallbladder problems, you need a general surgeon. If it’s due to pancreatic cancer, you need an oncologic surgeon. If the cause is Crohn’s disease, any gastroenterologist will do, but with Sphincter of Oddi problems, you’ll need a gastroenterologist who does endoscopic retrograde cholangiopancreatography (ERCP), and not all of them do. Now, of course, if you’re a woman, that abdominal pain may actually be referred pain from ovarian cancer, best treated by a gynecologic oncologist, which if you’re anywhere in Maine means a drive down to Portland.

The other day I saw an older man for a second opinion. He had been through one hand surgery for a small tumor many years ago in Boston, and had another unrelated operation for a fracture in Bangor a few years ago. Then, after a non-surgical injury, he developed stabbing pains in the same hand. Someone referred him to a neurologist for electromyography (EMG) testing, which was normal, and the man told me that was all the neurologist did, not a full consultation.

The man, who has traditional Medicare and thus the right to see any specialist who accepts Medicare, wanted me to get him get in touch with the brilliant Boston hand surgeon. The man told me he wanted a diagnosis and a cure, and not just a bunch of pills, which is what his family doctor had offered him.

"I won’t take gabapentin, I mean, with all those side effects," the man said.

"Did anybody suggest the diagnosis of reflex sympathetic dystrophy or regional complex pain syndrome?" I asked.

"No, is that the name for what I’ve got?"

"I think so," I told him. "And I don’t think even the most brilliant hand surgeon can help you. Around here, this is a problem that physiatrists or rehabilitation specialists handle. I think you should see Dr. Paul DeBeck."

"What would he do?"

"Confirm the diagnosis and probably offer you medication to start."

The man frowned.

"The list of side effects is only a list of possibilities. It’s published for legal purposes, so you can’t sue the drug company for not warning you," I explained. "I mean, would you drive a Jeep, or any car, on a public road if you read a document that said your gas tank could explode if you got rear-ended, you could hit a moose, you could roll over if you went through a curve too fast, you could slide into a ditch on an icy road, or you could get impaled if you drive too close behind a logging truck …"

"Anyway," I continued, "I think your problem is not surgical, so going all the way to Boston would probably be a big waste of your time. I suggest you ask your doctor for a referral to Dr. DeBeck, right in Bangor. Then he could guide you from there, even if he doesn’t think it is what I think you have. He sees a lot of that type of problem, so he’ll know."

The same day, I saw a woman with "hip pain," which turned out to be on the lateral, outer side, of her hip and a little toward the back side. That spelled sciatica from lumbar disc disease. She had wanted an orthopedic referral. But in the northern half of Maine, almost none of the orthopedic surgeons deal with back problems, so an orthopedic referral would have been a terrible waste of time for her.

I sometimes wonder why it is that medical specialties are divided up the way they are; you need to know the diagnosis before knowing what specialist to see. I mean, why isn’t there a belly pain specialty? But that is why it makes sense to see a generalist first. Plus, we are qualified to treat most cases of the majority of diseases people have.

Hans Duvefelt, MD, is a family physician who blogs at acountrydoctorwrites.com . This post also appeared on KevinMD .

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