Wednesday, November 17, 2010

Are PCP's The New Nurses?

It happened again last week. I received a consult note in the mail. My patient had seen the cardiologist for a follow up on cardiac disease. As I perused the assessment and plan I came across a new entry in the problem list:

1) Dizziness: refer to neurology

As opposed to yelling at the cardiologist and demanding that he refer patients back to me for work up....I called the patients daughter. I explained to her that dizziness can have many causes and only a small percentage of them are neurological. Although, of course, I trust the cardiologist could she have her mother please come see me first before going to yet another doctor.

The mother and daughter dutifully appeared days later. After a few minutes of questioning and a basic physical exam the cause became obvious. She was orthostatic and dizzy upon first rising. Her blood pressure was 90/60. I cut back on her cardiac medicines and followed up by phone two days later. Like magic....her dizziness was gone.

I can't tell you how often this happens. Cardiologists refer my patients to neurologists. Neurologists to orthopaedists. Orthopaedists to ENT. And often if they would just refer back to me I could take care of the problem much quicker (it can take months to get into a specialist) and often with less diagnostic testing.

I am not saying I can handle every issue...but usually I want first crack at it. Because I know the patient, I know the medical history, and I know the meds...I am much less likely to disturb the balance of chronic medical issues when treating somehting new.

But that's the problem with primary care today. We are not seen anymore as the problem solvers. We have lost a great deal of respect from our colleagues and patients.

In some ways I feel we have gone the way of the nurse. Much maligned by both physicians and society, nurses continue to toil behind the scenes with great amounts of knowledge and ability. It's just no one recognizes it.

Some days I am the cardiologists nurse, some days the neurologists, other days the dermatologists.

PCP call the pharmacy and order another months worth of medications
PCP insurance requires a requisition for that test
PCP write out a referral to another specialist because I can't figure this out
PCP the patients dying...go talk to the family about hospice!


WarmSocks said...

Do you think, then, that patients should return to their primary physician before scheduling referrals that one specialist makes to another?

Jordan Grumet said...

Warm Socks...

Yes...If my patient is seen by a specialist and they encounter a problem that is outside of their field...they should send them back to me.

If, however, a specialist sees a patient and wants to refer to another in their field (for instance a cardiologist sends my patient to an interventionalist for a cardiac cath) they do not neeed to go through me first.

The reason why is simple...often the referrals are inappropriate or unnecessary. Sometimes the specialists just don't realize it because the problem is outside their area of expertize.