By Karen Roush, MS, RN, FNP-C, AJN clinical managing editor
Recently someone I know woke up in the middle of the night with severe foot pain. In the morning he headed to the ED, where he was diagnosed with a fracture of one of the sesamoid bones in his foot and sent to an orthopedist. Over the three days between the ED visit and the orthopedist appointment, the pain began to ease. At the orthopedist it was determined that the problem wasn’t that little sesamoid bone, but gout.
And then they sent him to a rheumatologist.
Why? The condition was already improving and he had no comorbidities. So, why the need for a specialist visit at a cost of $500 just to walk through the door as a first-time patient? A primary care provider should be competent to manage a straightforward case of gout—order and review bloodwork, prescribe medications, educate the patient about their diet, and follow up on their progress. Then if the patient doesn’t respond to treatment or anything unusual develops, call in the specialist.
This happens all the time. When I was first diagnosed with hypothyroid I was sent off to an endocrinologist (under protest). There was nothing unusual in my presentation and I had no comorbidities or history that would indicate the need for a specialist. Again, a primary care provider is capable of reviewing thyroid panels, assessing the patient’s signs and symptoms, prescribing medication, and following up. But treatment was delayed for three weeks while I waited—feeling fatigued, achy, and depressed—for my visit with the specialist, at a cost of over $400.
Same thing recently when a friend of mine wanted to start on topical estrogen for atrophic vaginitis—her women’s health NP, who had seen her for years, insisted she go to a gynecologist. She had no comorbidities, no risk factors that would contraindicate the use of topical estrogen, which is a safe and straightforward treatment for most women. So, now she goes off to a physician who doesn’t know her for a repeat pelvic exam, a painful procedure in someone with vaginal atrophy, at the cost of $350 to walk through the door.
It’s not just a problem of delayed care and less continuity of care—multiply the above scenarios by the thousands of similar scenarios across the country and it’s obvious that the economic costs are tremendous. These costs are reflected in higher health care insurance premiums and costs of public programs like Medicare and Medicaid.
I practiced for years as an NP in a network of health centers serving a large rural population in the Adirondacks. I loved it—I saw everything and had the autonomy to manage patients through all kinds of urgent and primary problems, plus the physician support to back me up when I needed it. I managed countless people with gout and hypothyroid, and guided women through menopause and its myriad symptoms and associated problems. All of the primary care providers in the network did.
When a patient had complicating factors or greater risks of adverse outcomes, or didn’t respond as expected to treatment, then we sent them to a specialist. Even then, we often began with a phone consultation before referring them for a visit. This is how the family doctor or “GP” practiced for many years before us.
What changed? Worries about liability? The trend toward overspecialization of nursing and medicine? The expectations of health care “consumers”? The increase in physicians entering specialty practices versus family practice? The health care reimbursement system?
I don’t know. But it’s time for us to take a good look at the place of specialty care within our system and to encourage primary providers to practice to the full scope of their ability. Nurses are educated to provide care that encompasses the whole person—and with the Institute of Medicine Future of Nursing report calling on nurses to step up and “practice to the full extent of their education and training” and NPs being called on to fill in the shortage of primary care providers expected in response to the Affordable Care Act, this is an area where nurses can lead.
I think we all lose something in the current culture of specialization—patients and providers. I loved the diversity of my patients, the variety of problems they brought to my office, the opportunity to hone my diagnostic skills, and the satisfaction of seeing my patients through from diagnosis to resolution. And as a patient I know I want to see a provider who knows me head to toe, not just head or just toe—someone I trust to see me through and only send me off to a specialist when I really am “special.”
I am a relatively new NP, but I worked as a Army medic before I went to nursing school. I graduated in 2008 with FNP MSN. I do both primary and urgent care. I have my limits as to when to refer. Common conditions such as you mentioned is just plain wrong.
I have talked to some who believe that the specialist should see everything, just in case. What is the use of doing primary care ? I see alot of Derm in the ” urgent care” clinic that I work in. They come in because they can not come into see a PCP. I work for a inner city clinic as part of a country hospital system for the poor and uninsured.
Even getting a specialty referal takes several months anyway. So I do as much as I can in the mean time.
I have a little blog that is starting to take off at
http://www.medicstory.com
This is so true and part of the problem with our health care system. I have experienced this also with a goiter diagnosis. First thing my doctor did after me asking him to palpate my neck – was to refer me to an endocrinologist who prescribed Synthroid.
It’s very sad to hear that this is a common practice among some heatlh care professionals. $500 just to see a specialist when their foot condition is clearing up doesn’t provide any benifit to the patient, and as you said it appears that their foot condition and treatment could have been handled by the ED and the orthopedist. Thank you for sharing your views on this topic
Karen,
As I started reading this I immediately thought about the upstate health network we both loved. We, downstate, refer to specialists for several reasons. Primarily because we can. If the patient has insurance coverage the specialist will see them.
There are some who refer anyone for fear of liability. In my current practice, at a public hospital, I try to refer only those who really need the care of a specialist. My patients frequently have low health care literacy and expectations.
Your writing highlights the health care disparities between rural/urban practices and insured/uninsured patients.
Much work is to be done. Thank you for writing.
Rose
Excellent “spot on” analysis. One factor contributing to this phenomenon is pressure on primary care doctors/providers to keep visits short. The knee-jerk response by many is either the prescription pad and/or referral to as specialist. Exaggerated malpractice fears compound this response with complex cases that used to be managed (usually better) by primary care providers.
With our growing epidemic of chronic diseases – and multi-morbidity chronic diseases – this trend is likely to continue and expand. And it’s not for the better.