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.