What to Do When It’s Time to Let Go … of the Specialist

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So, how do we get our colleagues to let go, to stop taking care of our patients?

Seems like a funny thing to ask. Don’t get me wrong, we need our specialist colleagues; we value the care they provide and their expertise and assistance. We in primary care would probably be pretty much lost without them. But there certainly comes a time when it would be best, in the interest of efficiencies of scale, if they wrapped things up and returned patients to our care.

Often I have patients who come to see me as a new patient, and they tell me they have a cardiologist who prescribes medicines for their high blood pressure and cholesterol, an endocrinologist who manages their hypothyroidism and diabetes, a nephrologist who manages their chronic kidney disease, and a neurologist who takes care of their headaches. Wouldn’t it be great if we could figure out, at the start of a relationship, when it should end, when enough was enough, when patients could be evaluated by a specialist and then returned for ongoing chronic care to their primary care doctor?

Mostly we send patients to specialists when we’ve reached our limit, when we’ve tried A, B, C, and D, and nothing seems to be working. Or the patient has a problem that I’m just not comfortable managing, or I’ve been unable to even figure out what the problem actually is, or when this particular treatment or intervention requires a specialist’s delicate touch and vast experience.

As primary care providers have gotten busier and busier, it does certainly feel like the bar to refer people out for the management of a host of medical conditions has been set lower and lower. I have even heard that patients begin to dislike seeing their primary care provider and even avoid telling them about symptoms they are having, because they know that this is just going to lead to another referral, another specialist, another set of doctors’ visits.

We in primary care have a responsibility to be bold and to try and do our best to manage as much as we can, and only reach out for help when we absolutely need it, when it’s in the best interest of our patients. But how do we broach this subject with our specialist colleagues, or with our patients?

Sometimes the easiest way is to reach out to the specialist through the chat feature in the electronic medical record, saying, “Thanks so much for rendering that opinion on how to manage this problem for this patient; I can take it from here.” Or to tell the patient, “I saw the recommendations that the specialist I sent you to made; I’m happy to continue managing this problem for you, as long as things are stable and you are satisfied with the outcomes you are getting.”

Removing stable patients with problems that specialists don’t need to be managing frees them up to see new cases for us — the complicated ones we need help with. Far too often now, we call to try to get our patients seen by somebody and are told their next available appointments are 1, 3, 6 months or more out.

I think we can be better about setting these expectations up front, both with the specialists and with our patients: “I’m going to send you to Dr. X for an opinion about Problem Y, and they are going to tell me how to best manage this problem for you. The specialist may continue to offer some oversight, and can be available in the future if I have questions, or if you do, but we don’t expect this to be a long-term relationship between you and this specialist.” Maybe it would work best if we specify this up front in our request for consultation, so that everyone is clear that I’m sending them over for just a couple of visits to help work things out.

Because we are all on the same shared electronic medical record and we can easily chat back and forth about a patient, or even do e-consults, we should be able to free up our specialist colleagues so they can continue to see the challenging cases we really need them to help with.

I know, sometimes seeing someone that’s simple and well controlled in the course of the specialist’s day, when they are taking care of a huge panel of highly complicated patients, can seem like a little bit of a break, but it’s not really what they should be there for. They should be available for us and our patients when all hell breaks loose, and we are calling for help. And we should be available to them to take up the reins again once they’ve answered the call.

So maybe we can all work through our panel of patients and say, “I’ve got this; I can manage this for now; thanks for your help.” And our patients must be willing to let their cardiologist, their endocrinologist, their gastroenterologist, go. Then specialists might be more willing to end their relationships with patients, knowing that they are in good hands, back with their primary care providers.

Back where they belong.

Fred N. Pelzman, MD, of Weill Cornell Internal Medicine Associates and weekly blogger for MedPage Today, follows what’s going on in the world of primary care medicine from the perspective of his own practice.

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