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From Medscape Business of Medicine

Introduction

Thelinebetweenprimarycarephysicians(PCPs)andsubspecialists,neveraclearone,hasblurredevenmore.

ThepercentageofPCPscontinuestoshrink,andpatientseitheraskfororacceptroutinecarefromsubspecialists.Atthesametime,

internists,familypractitioners,andothergeneralists,inanefforttoboostincome,areencroachingonsubspecialists'territorybyofferingavarietyofancillaryservices.

JosephR.Arulandu,MD,aninternistinLaPorte,Indiana,isacaseinpoint."There'snothingmoreirritatingtoprimarycarephysiciansthan

whentheyreferapatienttoasubspecialistwho,afterdoingwhatisasked,proceedstotreatthepatientforroutineissuesthatcanbe

handledbythePCP,"saysArulandu.

"Thisisthebestwayforaspecialisttoloseareferralsource,"hesays."Ontheotherhand,IdoalotofancillaryworkinmyofficethatIused

tosendouttospecialists,andthereforeIneedspecialistslessnowthanIdid10yearsago."

Onereasonthatsubspecialistsaredoingprimarycareproceduresisthatinsomeareastherearen'tenoughgeneraliststogoaround,says

Fayetteville,Tennessee,internistJ.FredRalstonJr.,MD,presidentoftheAmericanCollegeofPhysicians.AccordingtoAmericanCollegeof

Physiciansfigures,approximately30%ofUSphysiciansareprimarycaredoctors;inotherpartsoftheworld,thatnumberiscloserto50%.

Theextenttowhichsubspecialists"co-opt"generalists'patientsvariesfromlocationtolocation,oftendependingontheavailabilityof

generalistsandthecompetitiveatmosphere,Ralstonnotes.It'slesscommoninunderpopulated,poorlyservedareas,andmorecommonin

denselypopulatedareaswherephysiciansmustcompeteforpatients.

When a Referral Becomes a Surrender

"Gonearethedayswhenyousentapatienttoasubspecialist,theymadesuggestionsandrecommendations,thensentthepatientbackto

youtoprovidecare,"saysaninternistinthesouthwestwhoaskednottobenamed."It'sveryclearthatawell-trainedsubspecialistcanalso

beanexcellentgeneralist."

"TheproblemisthatmostofthemlearnedlongagothatstayingintheendoscopysuiteorcathlabisfarmorelucrativethandoingE&M

services.Thefrequencywithwhichsubspecialistssetupreturnvisitsandtakeovermanagementofprimarycareproblemsisunprecedented.

Somearedoingitforpatientconvenience.Othersaredoingittomakeupforeconomiclosseselsewhere."

Somesubspecialistsaremorelikelythanotherstoholdontopatients.WayneS.Strouse,afamilypractitionerinPennYan,NewYork,

expressesannoyancewithendocrinologistswho"followstablediabeticsorstablepatientswiththyroiddisease,whentheyaresimplyreviewinglabsandmakingminoradjustmentstomedicationsthatIcouldeasilydo.Thiscausestheirschedulestofillupandmakesitdifficult

togeturgentcasesseen.Itbecomesa'catch22'inthatpatientsareafraidtostopgoingtoasubspecialistforfearthatwhentheyreallyneed

him,theywon'tbeabletobeseenformonths.Ofcourse,ifalloftheappropriatepatientswerereturnedtotheirprimaryphysiciansforroutine

care,thesubspecialist'sschedulewouldopenupandpatientscouldbeeasilyaccommodated."

Other Irritating Aspects

Evenmoreannoyingtoprimarycaredoctorsiswhensubspecialistsretainreferredpatients,butdon'tseethepatientsthemselves.According

toJ.ScottJordan,MD,afamilyphysicianinWhiteHouse,Tennessee,"Severalendocrinologistsandcardiologistsbeginactingasour

patients'primarycarephysician.Therealkickeristhatmostofthesespecialistsareutilizingmidlevelproviderstomanagethepatients.My

patientscomplainaboutthisapproachandwehavetoadjustourreferrals,butsomepatientsjustdoastheyareinstructedandfollowupwith

thespecialistsasrecommended."

Incertaincircumstances,subspecialistssay,PCPsaregladtocederoutinecaretothem.AccordingtoMarcNuwer,MD,aneurologistinLos

Angeles,"Icareformanypatientswithepilepsy.Thoseintheirteensthrough40softenusemeastheironlyphysician.Someover50doso

too,butthereIprefertosharedutieswithaninternist.Otherwise,Icarefortheroutinemedicalissues,cancerscreening,andother

preventivehealthissueasifIwereaninternist.IamafellowoftheAmericanCollegeofPhysicians,andIthinkofmyselfasaninternistina

way."

Authors and Disclosures

Author(s)

Gail Garfinkel Weiss, MSW

Freelancewriter,Merrick,NewYork

Disclosure:GailGarfinkelWeiss,MSW,hasdisclosednorelevantfinancialrelationships.

zGGGzGGwaGwGjGGzGailGarfinkelWeiss,MSW

Posted:08/09/2010

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Dr.Ralstonagreesthatsometimesit'sbetterforallconcernedifasubspecialistassumesprimarycareduties--foratime."Incasesof

patientswithkidneyfailurewhoareondialysis,it'sappropriateforthenephrologisttoalsobetheirprimarycarephysician,"hesays.

"Sometimesaparticularillnesstakesovereverything.Oneofmypatientshadcoloncancerthattheoncologistmanagedwhilehewasunder

treatment.Afteraboutayear,whenthosetreatmentstaperedoff,hecamebacktometoreestablishcare."

Patients With 1 Primary Care Doctor too Many

Ingeneralists'views,akeyfactoriswhethersubspecialists,aftertreatingreferredpatients,knowwhentostepaside.SomePCPsthinkthat

subspecialistscrossthelinewhentheybegincoordinatingcareforpatientswhohaveaPCPwho'swillingandabletotakecharge.

MitchellCohen,MD,aninternistinElma,Washington,offersanexample:"Isendapatienttoacardiologistforevaluationofchestpain,and

whilethepatientistherethecardiologistnoticesthatshehasaskinlesiononherback.Insteadofsuggestingthatthepatientreturntometo

evaluatethelesion,thecardiologistrefershertoadermatologist.Notonlydoesthisresultinthepatientwaitingmorethan3monthstobe

seenbythedermatologistinsteadofmaybeaweekforme,italsorobsmeofpotentialrevenueandshowsalackofrespectfor--and

knowledgeof--myscopeofpractice."

JeffreySchultz,MD,afamilyphysicianinBaltimore,Maryland,callsthisapproach"specialistre-referral"andsays,"Sendingpatientsfrom

thespecialist'sofficetodifferentdoctorsIhavenorelationshipwith,andgetnoreportsbackfrom,makingitsonoonedoctorknowswhatis

happeningtothepatient,whatmedicinestheyaretaking,whatteststheyhavehad--isarecipefordisaster."

AccordingtoLoriHeim,MD,presidentoftheAmericanAcademyofFamilyPhysiciansandahospitalistinLaurinburg,NorthCarolina,

subspecialists'understandabletendencytofocusontheirareasofexpertisemakesthemlesslikelytoidentifyproblemsinotherareas.

"Manyofourpatientshavemultipleconditions--perhapsacombinationofdiabetes,hypertension,anddepression,"shesays."Ican'ttellyou

thenumberofpatientswho,ifthey'reonlyseeingasubspecialist,havenoanswertoquestionssuchas,Whenwasyourlastmammogram?

Whenwasyourlastpapsmear?Whenwasyourlastcolonoscopy?Whenwereyoucounseledaboutquittingsmoking?Youseem

depressed;hasanybodyaskedyouaboutthat?"

Theotherpartofthisequationiscost.Heimcitestheproverb,"Itistempting,iftheonlytoolyouhaveisahammer,totreateverythingasifit

wereanail."Shecontinues,"Aguywithchestpainsisevaluatedbyacardiologistwhofindsnoevidenceofaheartproblem.Theguythen

getsreferredtoagastroenterologist,afterwhichheseesapulmonologist--eachtimeundergoingasuccessionofexpensive,time-

consumingtests,allofwhicharenegative.FinallyheseesaPCPwho,inlookingatthepatientfromageneralistperspective,zeroesinona

musculoskeletalproblem.Sodiagnosisandtreatmentaredelayed,andthepatientrunsuphugemedicalbillsbecauseeveryonewaslooking

onlyattheirpieceofthepuzzle."

Patients Who Prefer 1-Stop Shopping

AndrewM.Star,MD,anorthopaedicsurgeoninWillowGrove,Pennsylvania,acknowledgesthat"Wecontinuetoseelargenumbersof

patientswhoskiptheirprimaryphysicianandcomedirectlytous."Starmaintainsthat"wehavealwaysdealtwiththisissuetoadegreeand

ithasalwaysworkedoutwellintheend.Weareperceivedastheultimateexpertssothepatientswhoneedusfindus."

Still,somesubspecialistsarecarefulnottotreadintoprimarycareterritory.SivaprasadD.Madduri,MD,aurologistinPoplarBluff,Missouri,

notesthatoncehetakescareofreferredpatientsandtheyarestable,headvisesthemtogobacktotheirprimarycarephysician--although

somefailtodoso.

Onereasonisthatmanypatients,eventhosewithoutseriousconditions,prefer1-stopshopping,soifthey'reseeingasubspecialistregularly

theymighttrytogetthatphysiciantohandletheirothermedicalneeds.AccordingtoSharonPacker,MD,apsychiatristinNewYorkCity,

patientsaskhertodiagnosenon-psychiatricproblemstosaveco-paysortoavoidtheinconvenienceofschedulingappointmentswithother

physicians.

"Iremindthemthatmyexpertiseingeneralmedicineis35yearsold--butmyexpertiseinpsychiatryis35minutesold,sinceIgetemail

updatesalldaylong,"shesays."AndthenIreferthembacktotheirdoctors.OrIfindthemaprimarycarephysicianiftheydon'thaveone.Ibelievethathelpingapsychiatricpatientsecuregoodmedicalcareisanotherwaytoimprovetheirmental--aswellastheirphysical--

health."

And"patientstealing"islessofaprobleminareaswherereferral-basedHMOshavetakenhold."Iusedtohavemoretroubleyearsagowith

specialistspoachingpatientsfromus.Now,duetomanagedcare,patientscan'tkeepgoingtosubspecialistswithoutareferralfromme,"

saysStevenGitler,MD,afamilyphysicianinCamden,NewJersey.

"IfapatientisrequestingareferralthatIdon'tthinkiswarranted,IwillexplaintothepatientthatIcanmanagemaintenancecareand

treatmentoftheirconditionandthatitisn'tnecessarytokeepreturningtothespecialist,"saysGitler."Mostpatientsarequitehappytohear

thatsinceinthisareaspecialistco-paysaretypicallyhigherthanprimarycareco-pays.Itisalsomucheasiertogetanappointmentwithme

thanwiththesubspecialists."

The Generalist as Specialist

The"patientco-option"meterswingsbothways.

Primarycarephysicians--anxioustoincreaseincome--moveintoterritoryonceoccupiedalmostexclusivelybysubspecialists.Whenthe

AmericanAcademyofFamilyPhysicianssurveyeditsmembersin2008abouthospitalservicestheyprovide,findingsindicatedthat

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approximately35%docoronarycare,30%interpretelectrocardiograms,26%providepsychiatricservices,21%dominorsurgery,and11%

docolonoscopy.

Atthesametime,generalistsareaddingmorein-officeservices.Approximately5yearsago,familyphysiciansBethandFranciscoHodges

(bothMDs)begandoingin-houselabtestingintheirAsheboro,NorthCarolina,practice.Thetestsweresuchpatient-pleasersthatthe

Hodgesesswungintofullancillarymode.

Theynowofferbonedensitometry,pulmonaryrehabilitation,achildren'sasthmamonitoringprogram,in-officeultrasound,cardiacstress

testing,andadiabeticcounselingprogram.Laterthisyear,theyplantoaddcardiacrehabilitation,nutritionalcounseling,andotherservices.

Theresult?AccordingtoBethHodges,"Ourpatientsaremorecompliantbecauseitislessexpensive,lessintimidating,andmoreconvenient

forthemtohavethingsdonewithinourwalls."

InternistShereeB.Lipkis'ssolopracticeinGlenview,Illinois,isalsoancillary-rich.Inadditiontoemployinganursepractitioneranda

neuromusculartherapist,shedoesHolterandeventmonitoring,aswellasultrasounds."Inmyopinion,theonlywaythatnon-concierge

primarycarephysicianscanstayafloatfinanciallyistobemoreprocedure-oriented,becausewearereimbursedbetterforproceduresthan

forthinkingthroughandmanagingapatient'sproblems,regardlessofhowcomplex,"saysDr.Lipkis.

WayneS.Strouse,MD,inPennYan,avillageof6000intheNewYorkFingerLakesregion,mentionspatientconvenienceashismain

motivationfordoingnon-generalistwork.Becausethenearestbigcity,Rochester,isabout90minutesaway,hisprofessionalrepertoire

includespsychiatricanddermatologicalservices.

Financial Challenges Arise

Somesubspecialistsarefeelingthepinch.M.P.RavindraNathan,MD,acardiologistinBrooksville,Florida,saysthatmanyPCPsinhisarea

haveechomachinesandstresstest/nuclearimagingfacilities,anddocarotidandperipheralvascularstudies."Onelargefamilypractice

groupissowell-equippedthattheircardiologyreferralstomehaveceased,"hesays.

Forthemostpart,generalistswhohavesuccessfullybeefeduptheirpracticeswithservicestheyusedtoreferouthavean"all'sfair"attitude,

notingthatsubspecialiststypicallyout-earngeneralists."Medicinehasovervaluedproceduresasopposedtojustface-to-facevisits,"says

LoriHeim,"Primarycarephysicianswhoreferoutthoseproceduresareinfactlosingrevenue."

Anoptimumprimarycaresetting,saystheAmericanCollegeofPhysicians'FredRalston,ispatient-centeredmedicalhomes,inwhich

patientshaveanongoingrelationshipwithapersonalphysicianwhocoordinatescareacrossallaspectsofthehealthcaresystem.Thatwill

attractmorephysicianstoprimarycare,saysRalston,andmakeiteasierforpatientstogettheprimarycare,andthesubspecialistreferrals,

theyneed.

Determining Who's in Charge

Whatshouldgeneralistsdoiftheyfeelasubspecialistisunnecessarilyencroachingontheirterritory?"OntherareoccasionwhenInoticea

patternofpatientsbeingreferredtoaparticularsubspecialistandnevercomingbacktome,Iwon'thesitatetostopusingthatspecialist,"

saysfamilypractitionerStevenGitler.OccasionallyGitlerwillcallthedoctor."I'lllethimknowthatI'mreferringpatientsforevaluationandI'd

likethemsentbacktomeoncetheirconditionisstabilized,"hesays

Dr.Ralstonrecommendsthatgeneralistsstartwithaphonecalloraletteroutliningtheirconcernsandindicatingwhyitisinthepatients'best

interestforthemtoreturntotheirprimarycaredoctor.

AmericanAcademyofFamilyPhysicianspresidentLoriHeimalsosuggeststakingadiplomatictack--forstarters."Ifthesubspecialist

doesn'treferthepatientbacktotheprimarycarephysicians,thePCPshouldcontactthesubspecialistanddiscussthis,"shenotes."BeforeI

becameahospitalist,that'swhatdidifIreferredapatientanddidn'tgetatimelycommunicationbackastotheirdiagnosis,treatment,and

conclusions.Thesubspecialist'sresponsewouldhaveadefinitiveinfluenceonfuturereferralsfromme."

Heimcontinues,"Sometimesthesubspecialistsaysthatpatientsprefertoremainwiththem,butthat'sprobablynotthecaseifthereisa

patternofprolongedcareandthepatientsaren'tfollowingupwiththeirprimarycarephysician.Ifoundthatmostofmypatientsinsistedon

comingbacktometoconfirmthattheyshouldfollowtheadviceofthesubspecialist."

LikeRalston,Heimpointstotheneedforthepatient-centeredmedicalhomewhere,shesays,"wealignthefinancialincentivesaround

qualitypatientcareandnotjustonthevolumeofproceduresorvisits."

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