Early in my fourth year of med school, when I was trying to decide what type of residency to apply for, I realized that I enjoyed the breadth of the scope of practice a family physician embraces. I tell my patients that I specialize in what they walk through the door with. As a family physician I have to be comfortable and competent at seeing nearly any patient for any problem and helping them access the care that they need for the problem they present asking for help with. In addition I have to try to recognize problems or health risks that they may not recognize, and have to find a way to let my patients accept what I feel is appropriate preventative care and disease management.
I often am asked by patients if they should come see me or if they should just go directly to the specialist they feel is going to be able to definitively address their concern. I don’t mean to sound pompous here, but often patients are way off base in choosing the specialist best suited to their problem. Seeing a specialist in an arena of healthcare different from your problem has several risks. These include significant delay in receiving appropriate care, incurring the expense of extensive testing in their area of interest prior to reaching the specialist appropriate to your circumstances, overdiagnosis, and missing related or unrelated problems that a family physician may recognize but a sub-specialist may not notice. Let’s go through these in more detail:
- Delay in Receiving Appropriate Care: This can be the result of various causes. The one most concerning to me is when a patient makes a self-diagnosis and sees a specialist in that field. Often symptoms that seem related to one area expertise are caused by a disorder not apparent to the patient. Epigastric pain and nausea may be the result of heartburn and a gastroenterologist may be suited to evaluate and treat the pain. On the other hand it may be related to coronary ischemia and need urgent intervention. Seeing a gastroenterologist is not only not going to help, but may delay care, either because of a longer time to get an appointment for evaluation or because specialists often extensively evaluate issues in their area of concern prior to referral to another specialist. The time to have a trial of a medication for acid reflux and have an endoscopic exam of the esophagus and stomach may be detrimental to the care of a patient with coronary disease.
- Incurring Expensive Testing: When a patient sees a family physician they are likely evaluated for the most serious or most likely problems causing their symptoms. The list of potential concerns often extends across several areas of sub-specialty interest. By looking at the most serious and most likely issues first a family physician is more likely to avoid expensive tests for very unlikely problems. An example might be a patient with groin pain. If this patient sees a family doctor, they will probably be evaluated by history and physical exam for things like inguinal hernia, urologic causes like kidney stone and infection, hip pathology, in women ovarian-gynecologic issues including ectopic pregnancy, gastrointestinal causes and neurologic causes. If they see a urologist they are likely to have extensive evaluation for urologic problems, and may get a correct diagnosis of a kidney stone or UTI. If their problem very likely a gynecologic problem, they are still likely to have extensive evaluation for the urologic issues because no specialist wants to miss a diagnosis in their field of expertise no matter how low the likelihood may be. This holds true for most specialists. If you see a sub-specialist you are very likely to have an extensive evaluation for problems in their scope of practice whether or not they think you likely have a problem in their realm. A family physician is more likely to go through a process of looking for problems they consider important and likely, and put off extensive evaluation for very unlikely diagnoses. The cost savings of the latter approach can be huge.
- Overdiagnosis: I’ll be brief here, but if you have imaging like an MRI, CT scan, ultrasound or even many lab tests abnormalities are often noted that can lead to extensive testing which has its own risks, or diagnosis of a problem that does not now nor will ever bother you. The latter is called overdiagnosis. See a prior post on overdiagnosis for more information on this topic.
- Missing related or unrelated Problems: A specialist while highly trained in their scope of practice may not be focused on related or unrelated important health care issues. If you see a cardiologist it is unlikely that they are going to recognize that you are due for a mammogram and urge you to get a preventative care visit for this and other preventative services you are due. If you see a dermatologist it is unlikely you will bring up your “Oh doctor, by the way I am having these odd numbness and weakness symptoms,” that may lead your family physician to consider a TIA and make interventions to prevent stroke. The list of similar situations is nearly endless.
I feel pretty strongly that the first point of care for most health concerns should be either your family physician or the emergency department for life threatening emergencies. The scope of practice of your family physician gives you the best chance of efficient, timely and effective care.
January 1, 2012 brought another layer of documentation mandates to every office visit progress note. Meaningful use regulations added to chronic pain regulations in Washington have changed the context of many patient visits. As of Jan 1 of this year I feel like I’ve crossed over the edge and now have to spend more time as a clerk than as a physician interacting with my patients. I’ve succumbed to well-intended, government-imposed veiled threats and financial incentives, you could say fear mongering and bribery by our governments. This has led me to agree to yet more documentation in every visit to show that in the case of pain management that I am complying with many abuse prevention practices, and in the case of Medicare my use of an electronic medical record shows meaningful use. I guess this is as opposed to meaningless use.
Rebound headache is a well documented phenomenon that results from overuse of headache medications. I think I’ll use rebound headaches as the first of a series of posts on rebound phenomena in medicine. Our body seems to respond to the use of certain medications for treatment of problems by having the condition recur even more dramatically after discontinuation of the medication.