The days of the primary care gatekeeper are coming to an end

The American Journal of Surgery had a nice little (38 patient cohort) study from the VA database that tried to determine the process by which patients make informed decisions on elective surgery.  The results were rather surprising, at first glance.

Sixty-nine percent of patients decided to have surgery before meeting their surgeon, and 47% stated that the surgeon did not influence their decision. Although the surgeon was an important source of information for most patients (81%), patients frequently described using information gathered before meeting the surgeon, such as other health care providers (81%) or family members (58%).

My experience seems to support this to some extent.

Many times, patients show up in my exam rooms absolutely certain that surgery is an inevitability.  I walk in, introduce myself, shake hands, and the first thing the patient says is “so when can you fix this thing, doc?” And what he means is the hernia jutting down into his scrotum.  It’s very unsettling, to be honest.  I look forward to the exam, the doctorly diagnostic part, the going through the motions with the stethoscope thing, the positive identification of alleged hernia and the subsequent 10 minute didactic soliloquy on the pathophysiology of hernias and rationale for surgery, which segues into surgical options and a comment on mesh (not the one you see on TV that erodes into your colon and causes untold pain, suffering, and possibly excruciating death and the like, as described in various 15 second TV ads from nefarious local litigation firms), the good kind of mesh, the post op expectations and pain control and when you can get on the elliptical and go up stairs and have sex with your wife again.  I like that part.  The explaining, that is.  Plus you mix in a few anecdotes and personal details and try to get to know this guy you’re about to operate on.

I don’t want to just sign him up for surgery.  I’m not some technician who simply performs as instructed, like some on demand porn star.  Professional satisfaction for a surgeon is highly contingent on the development of a trusting doctor/patient relationship.  And generally this occurs quickly, over the course of one or two office visits.  The intensity and rapidity with which this happens is an inevitable consequence of the fact that patient is contemplating giving consent for surgeon to open various body cavities, remove excess living tissue, malfunctioning organs, etc.

It’s not like when you take your car in for an oil change and Louie, your favorite mechanic, is off sick but Jaron is there and he would be happy to take care of it for you, so no problem, you say, go right ahead, whatever, it’s just a matter of untwisting a cap and emptying bad oil, injecting new.

So I wonder — is this a good thing?  This entire paradigm we have of primary care docs as gatekeepers who distribute patients to surgeons as they see fit may have outgrown its utility.  In the era of easily accessible instantaneous information, patients are able to do their own research and watch YouTube videos and Google images and they show up in my office sometimes even more knowledgeable that many primary care docs.  (As an aside, the diagnostic accuracy of a PCP when it comes to hernia is not as high as one would hope.  We have one person who is right 25% of the time.)

Further, why should a patient be forced to see a PCP before seeking guidance from the specialist who fixes hernias for a living?  So many times I hear from patients that the hernia had been there “for ages” but his primary doc told him “not to worry about it” until it started to bother him.  And eventually, when half his sigmoid colon is trying to strangle his left testicle, he gets referred to me because, you know, it’s now “symptomatic”.  (Aside #2: I recommend repairing any inguinal hernia that you can see from across the the room, a hernia that bothers you, even slightly, with certain activities, and any hernia in a female.)

What would be a better system?  One where the patient sought a surgeon directly, after self-education and a Google search?  Is the solution better collaboration between surgeons and primary care docs, along the lines of non-condescending education and audiovisual presentations? A dual clinic where patients saw surgeons and PCP’s concomitantly?

Jeffrey Parks is a general surgeon who blogs at Buckeye Surgeon.

View 59 Comments >

Most Popular