Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Saturday, September 09, 2006

What Comes Between Primary and Tertiary?

The definition of Primary care is easily understood: it refers to the first stop in the health care system for the average person confronted with accident or illness, as well as preventive care. Also fairly straightforward is the "tertiary care center", which refers to the big city medical center with high-powered specialists and expensive equipment that can nail down that elusive "zebra" diagnosis and treat patients with very complex problems.

Those who have mastered the concept of numbers may have noticed something missing. What is "Secondary Care"? The answer is specialists, and the care they are trained to deliver.

So what's the problem?

During specialty and subspecialty training for Cardiology, Gastroenterology, Pulmonology, etc. physicians are taught that they must make a diagnosis. Every possible condition -- no matter how unlikely -- must be ruled out. Cost should not be an object, because some rare condition could always be present. That is their job as the specialist after all.

Here's the thing: specialty care assumes a preselected population. When patients are properly evaluated first by a trained primary care physician, many will find themselves correctly diagnosed and treated without the need for specialty care. When specialists see only those patients whose diagnosis escaped the family doc or who didn't respond to the Primary's treatment, their "spare no cost" approach is perfectly reasonable. In fact, their greater expertise is the rationale for their higher fees.

But when applied to a general population -- people off the street who haven't seen another doctor first -- medicine as practiced by specialists is expensive at best and inappropriate at worst. How many times has a patient with chest pain and no other cardiovascular risk factors gone directly to the cardiologist and, after an EKG, echocardiogram and nuclear stress test, been found to have GERD? To the cardiologist, the fact that the patient came to him is all the rationale he needs to perform his full work-up, when in fact the patient, whoever is paying for his care (be it his employer, himself, or an insurance company) and the specialist himself would have been far better served if this patient had been seen by a family physician first to be appropriately evaluated and treated.

So why aren't the specialists our biggest cheerleaders? Wouldn't their lives be far more interesting seeing patients far more likely to actually have those zebra diagnoses, not to mention more lucrative? (Consultations pay significantly more than evaluation/management codes. Then again, Consult codes are often abused. But I digress...) Specialist care can get ridiculously expensive, mainly because of all the procedures they recommend for diagnosis and treatment.

The specialists need to get their act together, quit poaching our patients, and go back to what they were trained to do: Secondary Care.


At Sat Sep 09, 06:38:00 PM, Blogger MedStudentGod (MSG) said...

I think that there needs to be a "screening" mechanism in medicine. Too many people head straight to a specialist because they feel they already know what they have - an acute MI, gastric carcinoma, etc. and their primary care physician will not be able to handle it.

However, what happens when a PCP becomes that consult? When they've added so many spcialist machines in their office that a nuclear medicine scan, echo, stress test, PFT, etc. are ordered simply to pay the payments and make them more money. I've seen both sides and they aren't pretty.

At Sat Sep 09, 11:56:00 PM, Anonymous Anonymous said...

I can definately relate to this downside of academic medicine. I admitted a 34 hour old from a small outside hospital nursery yesterday with a history of a persistent murmur but who was otherwise doing wonderful. On arrival no murmur was present. Because the outside doc had already spoken with cards, who were the impetus for the child's transfer I was obligated to call them to the bedside. Despite my suggestion to discharge the patient immediately with no further work-up, the cardiologist attending thought it prudent to go ahead and order an ekg, 4 ext bp, cxr, pre and post sats, and an echo. This was uneccessary and kept the child at our facility overnight. The cards attending admitted flat out that the reason he wanted them done was because the child was sent to us and they had to make sure there was no possibility of an abnormality. Hardly an appropriate use of medical resources as far as I'm concerned.

At Sun Sep 10, 09:11:00 AM, Blogger #1 Dinosaur said...

MSG: The "screening" you're talking about is called "primary care". Furthermore, I have not personally seen *real* primary care people with lots of advanced testing in the office precisely because they don't generate enough revenue when used appropriately -- the big bugaboo. I have found those secondaries (pulm; cardiol) more likely to overutilize diagnostic modalities (echos, PFTs) as "screening" tests. (Thanks for the new post idea: a reminder of what "screening" really is.)

Dr. B: Thanks for the support. Aren't history and physical supposed to be the cornerstone of diagnosis, with other testing just for confirmation? At 34 hours if there's no more murmur in a well-perfused kid who's feeding well and doing everything else a 34-hour old is supposed to be doing (though some parents seem to think that should include solving Blues Clues by Tuesday; hopefully a standard only applied if the baby was born on a Monday) any academic cardiologist worth his salt ought to be discharging the kid. Sounds to me like sub-optimal care, not just poor resource allocation.

word verification: slgug -- how I drink that first coffee in the morning

At Sun Sep 10, 09:23:00 PM, Blogger Big Lebowski Store said...

You answered your own question, man. Specialists are getting paid. Even the busiest ones never call me and tell me to quit sending them patients.


At Tue Sep 12, 03:59:00 AM, Blogger Unknown said...

In the UK, there are occasionally calls to allow patients to refer themselves directly to a specialist rather than going via their GP.

Eh, as Flea knows, even with the help of Diagnosis, You're The Doctor, Kit or the more sophisticated SimulConsult I don't quite understand where we will get these fabulous self-diagnostic skills from to enable us to make appropriate self-referrals.

Regards - Shinga

At Wed Sep 20, 06:18:00 AM, Anonymous Anonymous said...

In Australia, you can't get to a specialist unless you have been referred by your GP or a hospital. That's why they're called 'specialists'.

At Mon Oct 02, 08:46:00 PM, Blogger outre said...

I'm one of those patients that self-refer. But I don't diagonose myself, I just work with my current diagonosis and find the apporiate specialists who are well knwon in the community of fellow patients like me.

My ins. doesn't require pcp referrals for specialists, I like it. All the specialists I DID get referred to were done by my neurologist(one of the self-referred specialist)so if I needed referrals, I'd have had to constantly call my pcp to get the paperwork which I'd feel bad about since he gets jack from my insurance co. So any 'extra' work I'd end up asking him to do would have made me feel mildly guilty. I can't believe how little my doctors get back from my curren ins company... esp my pcp


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