Primary-Care Docs and Specialist Care

Reader Comments
Back to blog

So the main problem is not giving people a chance to make a choice in the survey between 'usually' (which should be the baseline, barely acceptable category) to 'almost always'. 'Always' is unrealistic and impractical as your writers have pointed out. This is not a small detail but a big part of the issue hinges on patients can count on that info from the specialist being in the record when the follow up visit occurs. My elderly mother, getting care in a network model, never has previous visit information available when she is seen by a specialist or in the ER. Same ER, two visits one week apart and no history on the first visit available. It's a mess and we work very hard to try to have her medical history available. My HMO has a great EMR system and I can see my own lab results come through within hours of going to the lab and post-visit cummaries are there for me ane my PCP to see. From dealing with my mom it's clear there's a reall and serious problem for most getting specialty care. And it's wasteful and dangerous. -- there's a real problem even though good people are working at all points in the system against tremendous odds. But let's not shoot the messenger until we get an arrow with a finer point. Or something like that.

MKC of CA 4:35PM January 30, 2009

I agree that the study design seems kind of silly to say "always." That being said, the communication in both directions is dismal. As a PCP I see patients frequently without consult notes or even hospital admission/discharge summaries that they should have since their last visit. I also (in deference to the FNP) agree with the specialist that PCP's don't communicate back. Why? It takes too much time that is un-reimbursed. PCP's are scraping by, seeing more patients in less time. Their mindset is to move on to the next thing as quickly as possible. It isn't good, but it is reality.
The duplication of effort and the inappropriate tests due to lack of information is the untold cost of medicine. I think it is the biggest waste area. There is no communication and the system is set up so that communicating actually decreases the revenue of the provider. Hospitals don't mind non-communication because it increases the number of tests and hospitalization. Insurance companies would seem to be the ones to care, but they pass on the cost to consumers by increasing rates.
The ones truly hurt by this are the patients and taxpayers. The cost is staggering on both fronts; and those reforming the system would do well to giving this problem their first priority.

Rob Lamberts of GA 8:49AM January 24, 2009

I stumbled upon this debate in my search for a top neurologist. I have suffered for 2o years with the same crippling symptoms, have had numerous diagnosis, everything from Thoracic Outlet Syndrome to Degenerative Disk Disease to Stenosis. I went from every surgeon that I had seen to this point saying that there was nothing that could be done surgically to my most recent MRI in May of 08 and all of a sudden it went from no surgery to if I did not have surgery I would be paralyzed. I had a fusion, I had 4 opinions before surgery, one from the Cleveland Clinic who looked at my MRI and said it looked fine and the other three in agreeance to the need for surgery but with the exception of the levels. An Ortho Surgeon wanted to cut me from C2 to T1 saying that this would be the only true help, another being more conservative wanted to do C5/6 C 6/7, and yet another C3/4 5/6 6/7. I had the C5/6 6/7 done, I am still in excruciating pain, coupled with the severity of pain in my lower back and down my leg, and the fact that all of the symptoms prior to the cervical fusion are still present but more intense. Yet, I still can not get any of the doctors to communicate, find the source, or work on a solution, it is still one opinion after another frustrating opinion.
All physicians need to communicate with each other, as well as their patients, follow through is essential in order to come to an appropriate treatment plan, and to many patients are either lost in the shuffle and live daily with there problems un-diagnosed due to the lack of proper communication and most importantly LISTENING to what the patient has to say. I jokingly say to my husband they will find the root of my problem some day on autopsy after it kills me, but after suffering with it for the past 20 years and getting worse and worse, I may just be right.

Ann Marie Bezdziecki of FL 9:31PM January 20, 2009

Mom and Aunt Sara, The man with the HUGE SHOT an NEEDLE, the older doctor who cuts on you as well as does about everything else including writing a letter to the Army. Oh no, I'm moving out of state to a place I only have a cousin. Best call her to get the doctors name. Have no clue but how many doctors can there be in the 29th largest city in the US according to buying power. Time moves on and so does your health. Oh my, what on earth is an internist. Been told to find a good one as then I'll have a doctor that can do about everything except pull teeth but between you and me, I think he can. Huh, I can't go to my internist anymore? I can but I have to pay what?
I really don't understand this. Sooooo, if I get employment health insurance, etc. Here is a binder to look at and get some darts. Wait, these physicians are all nice and intelligent but when I said "Central Pontine Myelinolysis," they.... G-d bless as time moves on again. (~8
Franky (Canine Neuro Service Companion) and WhataBreeze (Me)

Franky and WhataBreeze of MO 8:47AM January 12, 2009

I employ both NP's & PA's in my busy cardiology practice. As ancillary personnel they do fine in many areas, ie follow-up in lipid & warfarin clinics, doing initial H&P's, and BP checks to name a few low-level tasks. However for more complex patients they tend to want to over-prescribe and order more expensive laboratory tests. I have to keep a close monitor on their clinical decisions. I will not allow them to practice independently, and any decision-making for referral MD's go through me.
If I or my family members need medical care we will always see a physician. Our health is too important to entrust to a non-physician. I realize there is a wide variation among physicians in quality of care, especially for primary care MD's, that's why if I have an orthopedic issue, I see an orthopedist; if I have a rash, I see a dermatologist. For routine health maintenance, it's hard to beat a high quality Internist, still the best captain of the ship.
Back to medical records and correspondences. EHR may be helpful, and will certainly be better than NO communication. But a sophisticated, complete, well-written letter is still the gold standard of information exchange. It however, like the nurse at the bedside, is going the way of horse drawn buggies.

outtafocus of KY 6:18PM January 08, 2009

The problem is that medicine in he United States is communist - the government pays for it and seds the prices. 90% of the money in the sysetm comes from medicare. The insurance comopanies all just use the medicare payment rates.
Surgery is wildly overpaid, primary care keeps getting squeezed.
Of course, everyone in med school wants to be a surgeon (15% revenue increases annually) rather than a primary care physician (cuts annually).
If we want to make this better all we have to do is get medicare to cut payment for all procedures that have a CPT code starting with 6 - surgeries - by 10% a year for 5 years and put half the money saved back into the other CPT codes.
Doctors aren't stupid, they respond to economic incentives. Currently the incentives are to get out of primary care and specialize. Change the incentives and doctors will change what they want to do.
If doctors don't want to take care of sick people there are plenty of other caring professionals around. The two best "doctors" I know are nurse practitioners. Probably because they care more about their patients than about how much they get paid to see them.

Andy of WA 3:35PM January 08, 2009

I am a family nurse practitioner and always, let me repeat ALWAYS send a letter and request for referral with a detailed write up of patient history, findings on physical exam, medications, primary care plan of care, and tests ordered/pending. I find that many of my FNP colleagues do the same. I do expect a detailed report back from the specialist as I am the one responsible for integrating recommendations,follow up, and medication management into their total plan of care. I find I can't even read most MD notes and if I can they are one or two lines at best and lead to not only a dearth of shared information and lack of opportunity for optimal patient care, but are dangerous in my opinion. EMR should help with this but it's going to be difficult if it is not standardized and trying to get the old timers on board-good luck! Patients might find better care, longer visits, more communication, and follow up by choosing a family nurse practitioners-all the studies point to the fact that we provide as good of/better than primary MD care and we have more time to spend to do the things the author suggests.

jaime of CA 2:48PM January 08, 2009

A.C., as if you can't already tell, I'm somewhat sold on your direction in regard to most points and on most health matters. We have been running our thoughts side by side for some time now. Actually we are a bit due to totally explode on one in the near future but let's ride the wave until then.
A few of my treating physicians for "Central Pontine Myelinolysis," while at Johns Hopkins back in 2005, use to say that my Blog, Postings and Thread's definitely use to justify my coming to Baltimore from "La La Land,USA." I continued to tell them it had to be the Myelin Pattern of Loss that is responible. By chance you surely could not of seen a piece I did in the newer mag called "Neurology Now," which happen to come out just less than about a year ago. It was in regard to putting a team of my second opinioned physicans together using my Internist as my Quarterback.
Guess what, I'm in the process of doing the exact same directive together again right now. You really hit the target on this one. I learned real quick and in a big way all about records while working a group like this in my best interest. I will say at this point I must of been blessed as it takes much of an overview to make sure it is working in mine or your best interest "WITHOUT getting in ANYONE'S way. I found that it was up to me to create ONE update report between even numbered visits/appointments. I will say and hope it's heard loud and clear that over doing is not good as well as under doing the same. Let's put it this way for the time being. What I have noticed in a MAJOR WAY is the change in the "Office Lineup," which strictly in my opinion is very strategic in having a successful running office. An important factor is to know who does what and be sure to remember whose position it is meaning their's or your's. Team work is GREAT but remember the "Over's and Under's earlier. What isn't successful today that did not have to go through a series of changes. If you think back to almost all industry's, it's happened. Those you can't remember didn't carry the importance of others. This one has my fingers sore and my hands numb. G-d Bless.... (~8

WhataBreeze and Franky (my neuro canine service companion) of MO 11:06PM January 07, 2009

Let me put this in a different light. I am a specialist physician, and I always send a letter of consultation back to my referring doctor, outlining my diagnostic & treatment plans. The letter is typed on company stationery and mailed directly to the MD office for their review. But I NEVER, let me repeat NEVER, ever, receive any correspondence from a referring doctor about why the patient is seeing me, or do I receive any follow-up whatsoever as to how the patient is doing, nor, is other specialists work-ups passed on to me. I also send a letter on the patients follow-up visits to me. In my opinion and experience, the "continuity of care and enhanced care coordination" is a one-way street. How dare internists complain about lack of communication!

Avery Comarow responds:Please don't clobber internists--patients, not primary-care physicians, were surveyed. But it is shocking to read your statement that referring PCPs never communicate with you in advance or follow up afterwards. All you get before meeting a patient is a referral slip? I'd like to know whether this echoes the experience of other specialists.

Dr P of KY 6:33PM January 07, 2009