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.

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  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    The job of the primary care physician is to coordinate the patients care. Even as a ” gatekeeper” in the traditional managed care system the PCP wasn’t funneling patients to specific physicians but assisting the patient in making a choice from a panel of physicians under contract to the insurance company if the patient asks for advice. The PCP’s role was to take a history and perform an exam and assist the surgeon in identifying issues that might contribute to the morbidity or mortality of the patient. Few if any family practitioners or general internists asked to be gatekeepers.
    The ideal situation would be the patient having a physician to provide longitudinal care and referring the patient to the best practitioner to perform the procedure required based on experience , skill, training and responsiveness of the surgeon.

    • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

      Dr. Steve, what happens if the patient doesn’t want to the practicioner recommended by their Primary Care Physician? The reason I ask this is because sometimes insurance dictates who the patient can see. The other reason I ask is because the patient may choose not to see a particular provider because that provider may not respect the personal or religious views of that patient when it comes to the way surgical procedures get done.

      • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

        My job as a physician is to assist the patient in finding a surgeon or specialist that they are compatible with. I usually tell the patient who I would go to that is on their panel and give them additional options. If they have a suggestion I will help them research the practitioner. If the practitioner is certified and experienced and treats patients well and communicates well why should I care if they go to one professional or another?

        • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

          Dr. Steve, thanks for your response. Have you ever had anyone refuse you trying to help them find a provider that can take care of the problem in question? I was just curious because of the fact that so many now go straight to the various specialists themselves due to the fact that depending on the insurance a referral is not required to see a specialist.

          • SBornfeld

            I’ll throw my 2 cents in. I should say up front that I’m not a physician (I’m a dentist).
            You know the old saw about the definition of a specialist?
            A specialist is a professional who knows more and more about less and less until he knows everything about nothing. I suppose the converse could be said of generalists (that they know less and less about more and more).

            But I hope that isn’t true. I was shocked (and I say this as an admitted curmudgeon and cynic) and dismayed by Dr. Parks’s comment about the PCP who was right about hernia 25% of the time.
            A little knowledge is a dangerous thing, Patients who self-refer often overestimate the quality of information on the web.

            I’d like to think that the average gastroenterologist who sees a patient coming for the first time thinking they have gall bladder disease can distinguish pain from a dissecting aortic aneurism, but if not I’d hate to be on the wrong end of that mistake.
            In a perfect world, any doc would make an appropriate referral. Asking for patients to do the same is too much to ask for.

          • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

            SBornfeld, thanks for your response. I was a bit surprised by the percentage figure quoted in the article as well.

          • Suzi Q 38

            Funny dentist story.
            My daughter had TMJ at the age of 14.
            Her dentist (my cousin) recommended a TMJ specialist.
            The specialist ordered a very expensive contraption, made especially for her, that she was supposed to wear at night.
            It cost us in 1999 about $2K. I didn’t question the price for whatever reason. Probably because the dental specialist taught at the best dental school in our state.
            We were not wealthy people. We had to finance the work.
            Well, we got the thing and tried it for 4 months and she still was in tremendous pain at night. The doctor told me that she needed to be fitted for a new one, and this one would cost an additional $1K. I hesitated, but agreed.
            That one didn’t work either.

            He then said that our only option was surgery.
            I refused. During that doctor’s visit he took xrays and tried to show me what the problem was. I told him “no.”
            He told me that he had already called the oral surgeon and I was to go downstairs and have him see her that minute. I got kind of scared. I said “NO WAY,”
            and walked out of there.
            I called my cousin up and told him what had happened.
            He was so angry that he would not refer another patient to him again, he said. Now we were out about $3K.
            That dentist (TMJ specialist) was so angry that he wrote me a letter. Telling me that I should not have walked out of his office like that since my daughter needed the surgery. I called the office and told the receptionist that I wasn’t coming back.

            I brought her back to my cousins office and he ordered her a cheap one that cost about $400.00. Believe it or not, it worked!

            She did not need surgery, and she grew out of it eventually.

            We did pay the $3K (insurance paid 1/2, I think), but under protest, and my cousin never referred another patient to him again.

          • SBornfeld

            Not ha-ha funny.

          • Suzi Q 38

            You’re right.
            Another surgery story, dentist style.

          • SBornfeld

            No, but it’s probably different in dentistry. We’re maybe 85% generalists; physicians are about 85% specialists.
            Besides, those who self-refer to dental specialists are the ones I often don’t get to see. ;-)

        • SBornfeld

          That’s a whole lotta “ifs”.

    • http://www.bryantsstatisticalconsulting.com Donald Tex Bryant

      Well spoken, Steven. I trust my overall care to my PCP. Wouldn’t have it any other way. My PCP is the only physician who has all of my medical history in place and knows the “complete me”, not just the hernia (never had one). My PCP does send me to a urologist each year but the PCP makes sure all of this is coordinated through his office and that the medical report of the urologist is sent back to him, at my medical home.

  • N N

    And the bashing of general internists and family practioners continues. Gotta love our own medical firing squad.

    • Suzi Q 38

      I don’t agree. It is really hard to be an internist. You have to know so much about the entire body, rather than just one part.

      I rely on my PCP to tell me if he thinks I need the surgery.
      He helped me get to other specialists like neurologists to rule out various other medical conditions that would not require surgery.
      I remember, though, that he did not have the time to write out a referral for me.
      I faxed him a copy of I letter I wrote for him: “Patient wants to rule out M.S., transverse myelitis, and other related conditions.”
      He thought that what I thought I needed was pretty good, so he faxed it in to the neurologist for me.
      In fact, I had 1 PCP, 2 neurologists, and 3 surgeons before I decided on one surgeon. That surgeon wanted me to wait until I had an MS doctor rule out M.S. for me. We were waiting for one more comparison MRI, but my symptoms took a turn for the worse. The signal changes in my cord were giving me permanent symptoms.

      I respected this surgeon because he hesitated to give me surgery, just in case I had M.S.

      I felt comfortable with him, and he was very confident.

      My PCP did not know him.
      My PCP has privileges at a hospital that does not accept my PPO insurance.
      He told me flat out that my condition was so bad that he had no clue. I respected him for that.
      He told me: ” Your condition is so complicated, that at some point in time, you have to go to see about 2 surgeons, and then trust and pick one.” He told me which teaching hospitals he preferred.

      I remember sending all of the CVS of the surgeons on staff to my son’s friend, who was a medical student at Columbia.
      He helped me pick based on types of surgery the surgeons performed, qualifications, and how I felt during the office visit.
      His brother was a neurosurgeon in Northern California ( I live in Southern California). That neurosurgeon personally called me and gave me more names to consider.

      I asked each neurologist if I needed a neurosurgeon or an orthopedic neurosurgeon…this stuff gets that confusing!
      They both pointed me toward regular neurosurgeon.

      I wish that my PCP could hav had some informed input, but alas, it was not to be this time.

      Just my personal belief system: I would not go to a surgeon without first checking in with my long-time PCP or a couple of specialized internists telling me that I needed surgery.

      I think that surgeons usually want to “cut.” That is what they do.
      I don’t mind that realization, but I just want to make sure that the one that decides that I need the surgery is NOT the surgeon.

      • SBornfeld

        I actually think NN agrees with you. His or her comments (as well as those of Dr. Hornstein) were directed at Dr. Parks.

        • Suzi Q 38

          Thanks. You’re right.

        • N N

          You are correct, SBornfeld, thank you.

  • 99bonk

    In Britain, patients must be referred to specialists by their primary care physician, who is expected to communicate with the specialist before the patient arrives, indicating the reason for the referral and any workup which has already been done.
    Lack of communication compromises patient care

    • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

      99bonk said, “In Britain, patients must be referred to specialists by their primary care physician, who is expected to communicate with the specialist before the patient arrives, indicating the reason for the referral and any workup which has already been done.”
      That’s good, but the question is how often do they really do it? I also agree about that lack of communication compromises patient care. The issue of communication between Primary Care Physicians and specialists is a big problem here in the U.S. Dr. Kevin wrote an article about this very subject about a year ago or so discussing this very issue at length, explaining just how big of a problem it is.
      The reason I asked the question about how often the Primary Care Physicians and specialists actually talk to each other is because I know how busy their schedules are. How much time do you all get to have with your doctors when you have an appointment?

      • Suzi Q 38

        Hi Kristy,
        You are right. The doctors had no time to do it.
        I had a big binder full of my own information when I had to see the neurologists to rule out MS and any other related conditions.
        In the binder, I had blood work results, LP, MRI’s of my entire spine. I would allow the “fellow” to photocopy anything that he and the M.S. doctor needed.
        I also had nerve study results and my optometrist’s findings from a recent check up.
        If they wanted additional blood work, I went and had it done, but reminded them to please look at the blood work that I already had done.
        I do it this way, because the doctors do not study my case beforehand and they do not talk to each other.

        • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

          Suzi Q, I agree with you. And reading what you wrote about what you have had to do backs up my point about why some patients would prefer to coordinate their own care. Me being amongst them. I think that because of the fact that they don’t have a lot of time to spend talking to each other like they once used to that may be why doctors like mine ask for the progress notes.

          I hope that your pain level is ok today.

          • Suzi Q 38

            “I hope that your pain level is ok today.”

            Thank You, Kristy.
            I am at about a 2-3. so I am going to “give in” and take 1/2 of a Tylenol for now. I will save my 1/2 of Norco for later, if I need it.
            I am so fortunate that I am O.K. with the pain.
            From what other doctors post, it is really bad for others.

      • 99bonk

        I have been living in the US for many years, so have not had occasion to “go through the system” recently, but in my former life, specialists usually took plenty of time with patients who came via referral (since they depended on referrals from PCPs for their living, and would suffer financially if patient feedback to the PCP was negative).

        • Suzi Q 38

          Yes, the first consult visit is good, but the follow ups are rushed.

        • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

          99bonk, things are much different now than they used to be. And the doctors here when it comes to scheduling are much more rushed than they used to be. Even 20 years ago when part of my time was spent on HMOs my specialists did not regularly talk to my Primary Care Physician as they should have. And my Primary Care Physician yes they would give me the referral to the specialist. Only a few times have I ever had a specialist communicate with my Primary Care Physician, and then that was usually by letter. Only one of my doctors that I was seeing regularly (but is now as needed) would regularly communicate with my other doctors. My Primary Care Physician that I have now wants progress notes from all my other doctors so that he knows what is going on with me. So that he not only knows what’s going on, but how I am doing especially if there are complications. But as far as actual talking, most doctors do not have that kind of time to do that anymore which is not a good thing. Because then that goes to where you were talking about the compromising of patient care. Lots of work needs to be done in order to make things better.

    • Suzi Q 38

      This is good, but has happened rarely with me. We are about to embark on a different healthcare system. I am hopeful it will be better, but fearful that it will not be.
      I still do not like the idea of waiting so long for procedures and surgeries. There are people living in Canada that drive to the U.S. for surgeries and pay cash.
      Sometimes this waiting game is good, but in other cases, it is not.

  • Suzi Q 38

    I went directly to a teaching hospital for my hysterectomy for pre cancer found on my cervix. It turned out to be uterine and a borderline proliferating tumor on my left ovary, along with cysts and polyps.
    I had a gyn/oncologist do the job, and I came out with weak nerves in my legs. I should have pushed for the more senior surgeon on staff, but I wasn’t aware that I could have done that.
    Now I have to deal with my weakening legs and I am not sure of what he could have done to “trigger” this phenomenon. Sadly, it happened soon after my surgery.

    I just gave the teaching hospital the name of my PCP.

    • meyati

      That’s gyn-the rules can be quite different for other problems and specialties.

      • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

        meyati, under my insurance plan gyns are considered Primary Care Providers so I don’t need to let my Primary Care Physician know that I have gone to her for anything. But yet my gyn considers herself a specialist. And when I saw her on Fri for something they charged me $30 for the visit. I questioned it and they said, “well, that’s what she has it down as that you owe”. I said ok but that I would check with my insurance. Good thing I did too. They should have onl charged me $20. So now a refund is coming.

        • Suzi Q 38

          I had a gyn, and I wanted a consult with a gyn oncologist, who specializes in female cancers. In case I had cancer, I wanted a surgeon that was more skilled in case I needed lymph nodes removed.

          • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

            Suzi Q, I can definitely understand the reason for that. And yes, I can see why a PCP would be required to get in if either the clinic themselves required it or if the insurance required it. With my PPO I don’t need to get a referral from my PCP to see any of my specialists.

          • Suzi Q 38

            I have PPO too, but when I contact the surgeon’s or specialist’s office they want to know who my PCP is.

            My PCP knows some specialists, but I may not want to use them because they are not practicing at the hospitals that my PPO covers. The main local hospital is not covered for me unless it is an emergency.

            I can go to any specialist too insurance-wise.
            My husband and I pay $850.00 on top of the $1000.00 a month that the employer pays for our medical insurance.

            For some people, that is equivalent to a small house payment. To hear some doctors complain about us patients that we “Just don’t want to pay for healthcare”
            is not true. There are many of us that “pay through the nose” and still get mediocre care.
            We can opt out and pay for HMO care for far less (about $350.00 a month). I still prefer the freedom of choosing my doctors, surgeons, and hospitals.

            I thought I was getting really good care. Yes and NO.
            Team work??No. There was no doctor or heath professional placed to assist me.
            I know now that we need to get one for ourselves.

          • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

            Suzi Q, Other doctors that I have been to also want the name of my Primary Care Physician as well when I go to them. Well, my regular specialists already know who my doctor is. When I went to get a second opinion about something I asked that doctor’s office to please not send the note to my PCP because the issue for why I was getting a second opinion did not tie in to him. It had to do with a test result from one of my other doctor’s offices.

            What you are talking about as far as what you pay all I can say to that is wow. It is true that sometimes no matter how much one pays out to get the care it is not always the best. Alot of work still needs to be done in order for healthcare to work the way it needs to.

      • Suzi Q 38

        O.K.
        That explains it.

  • http://twitter.com/DinoDocLucy Lucy Hornstein

    Right. Take the very specific instance of a (seemingly) straightforward surgical problem and declare all of primary care superfluous.

    If you don’t mind seeing people with epidydimitis, vulvar cellulitis, kidney stones (referred pain) and various other assorted non-hernia inguinal pathology, then by all means, put me out to pasture and sort it all out yourself.

    • http://twitter.com/buckeyesurgeon jeff parks

      I dont mind someone walking into my office, claiming to have a hernia, having me spend 2 minutes determining that, no, he actually has something wrong with his testicle and referring him out to urology.

      • http://www.facebook.com/profile.php?id=762893788 Dave Miller

        I bet you might mind that very much if that was 85% of your day, I think! Fortunately for you, however, we lowly primary care docs generally do a good job of weeding out the non-surgical cases and sending you ones that need your attention so that you can have the luxury of being efficient.

  • Suzi Q 38

    “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?”

    We have this already. This is called the Internet. I utilized this “tool,” along with my PCP and other specialists.
    CV’s are listed on each hospital’s website.
    I watched with fascination at a neuro radiologist from a famous teaching hospital give a talk to residents about myelopathies. She was excellent. I wrote to her, and she invited me to fly up north to get evaluated and treated, LOL.
    I looked up the neurology ratings as far as hospitals on U.S. News and World Reports. I found the information on the Internet.
    I listened to a neuro surgeon from Johns Hopkins who discussed what signal changes (spinal cord) were and when to seek treatment.

    There is already too much overload of information.
    Quite frankly, it is so much that at some point in time, you have to do the best you can and then trust.

  • Suzi Q 38

    “Further, why should a patient be forced to see a PCP before seeking guidance from the specialist who fixes hernias for a living?”

    The PCP costs only $50.00-$100.00 of my PPO insurance to see.
    I pay a $15.00 copay.
    I have developed a relationship with my PCP over the 10 or 12 years that I have gone to him. I trust him. Right or wrong on my part, I think he is fairly smart. If I have persistent symptoms, and he has no idea, I take the next step, and get a work up from a specialist.
    Sadly, most of us do not want to “jump” into surgery so early on.
    We would rather explore other options. Sometimes we win, and avoid surgery, and sometimes we lose, and the condition gets worse.
    There is risk with almost any surgery.

    We know what you, the surgeon, are going to say most of the time.
    That I am going to need surgery. Not all of the time, but most of the time.

    For these reasons, I prefer to see a PCP first, unless the condition lands me in the ER and I need immediate surgery.

  • http://www.facebook.com/jeffrey.parks.58 Jeffrey Parks

    I guess the point of post is this: Should patients gravitate toward self education via internet/advertising rather than rely on PCP for referral to specialists?

    • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

      Dr. Parks, patients already gravitate toward self-education via the Internet/advertising, family, friends, etc. Of course, that doesn’t necessarily mean that it’s safe to do this. But then again there are those that can’t afford to get to a Primary Care Physician to tend to these types of problems so they end up using the ER as a Primary Care Physician instead. Or else they use the options you mentioned and that I alluded to because they have no way to be able to go to a Primary Care Physician before going to the specialists. That’s why it’s going to take a number of different things that need to be done in order to try and fix the shortage of Primary Care Physicians in this country. Looking at just one thing as a fix for the issue to try and fix the problem is not enough. We all need to work together.

    • Suzi Q 38

      I would like to say that if I had a good referral (from the PCP), I would at least give the surgeon he referred me to a consult.
      If I did not get the best referral, I would have to to elsewhere to get another opinion or two. The Internet is helpful for a variety of reasons, but some of the information is subjective and at times, wrong.
      It just depends on what is the source of the information.

      For me, I used a combination of both for my last surgery, which was 1/18.

    • buzzkillerjsmith

      As a family doc of 23 years, I think it is fine that pts with hernias see you first. I am puzzled that other folks seem to have a problem with that. General surgeons are great at diagnosis, too.

  • http://www.thehappymd.com/ Dike Drummond MD

    Gatekeeper is such a completely inadequate term. It simple HAD to have been made up by a disgruntled specialist.

    What do you call someone who makes sure the whole of you is taken into consideration and refers you to the best specialist in the community, because they have a personal experience of working with them? I would call that a “health optimizer” or something like that.

    If your only tool is a hammer, everything looks like a nail. Surgeons are trained to operate … and only a small number of medical illnesses and injuries require surgery. In hind sight you can say something silly like, “Hernias can go straight to the surgeon” and the question is “who diagnoses the hernia?”

    If you are referred by an experienced primary care provider, you
    have been seen by a generalist – a person who knows about ALL the causes of your symptoms. (the differential diagnosis of an inguinal mass is long … hernias are just one cause) That person has looked at the whole situation and decided a surgeon is the solution. Your PCP sends you there specifically for that particular “Hammer” of treatment.

    Understand that there is a massive conflict of interest every time you see a surgeon – it is magnified any time it is a self referral. The only way to remove that conflict of interest is if the surgeon can diagnose and make recommendations, but cannot be the person who operates on you.

    A layer of primary care between the patient and the surgeon gives the best chance of the highest quality care and the most appropriate use of the referral specialist.

    My two cents,

    Dike
    Dike Drummond MD
    http://www.thehappymd.com

    • Suzi Q 38

      “A layer of primary care between the patient and the surgeon gives the best chance of the highest quality care and the most appropriate use of the referral specialist.”

      I agree.

    • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

      Well stated sir !

    • SBornfeld

      It MAY have been a disgruntled specialist, but it wouldn’t be how I would bet! ;-)

  • http://www.facebook.com/neurokc Aaron Seacat

    With more and more PCP’s now owned by hospitals I see it as a good thing that patients are doing their own research. In my region, a referral by a hospital-owned PCP to a surgeon or specialist has a 95% chance of being directed to a physician within the same hospital network. Buyer (patient) beware.

    • Suzi Q 38

      Yes! Thank you. I didn’t realize that fact. That is another thing to consider.

  • Docbart

    The title certainly embodies the author’s wishful thinking. The risk of some less ethical surgeons trying to maximize their activity and income is just too much for a system struggling to deal with over-consumption of medical services. I think the only way to have a system with direct patient access to surgical services is to have surgeons on straight salary or capitation plans, where there is no financial incentive to operate. I bet surgeons would be much more conservative then.

    • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

      I think that there would be a huge outcry if the surgeons were put on a straight salary or capitation plans. I think someone wrote a blog post on this site several years ago saying something about considering cutting the amount of pay specialists get.

      • Docbart

        It’s always very noisy when someone tries to apply the brakes to a speeding gravy train. BTW, I am not advocating salary or capitation, just speculating about the effect of doing so. Salary and capitation seem to cause undertreatment and delayed treatment- ask the British and Canadians how fast they can get non-emergency surgery done.

        • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

          Docbart, that’s a good point about it being noisy when someone tries to apply the breaks to a speeding gravy train. And as for the salary and capitation seeming to cause undertreatment, good examples of what goes on with the British and Canadian system. No wonder like one of the others mentioned that there are Canadians (and in some cases Brits too because I just recently read an article about a little boy with CP that was brought to the U.S. to have a specific kind of procedure that can help some kids but the family had to raise the money to come here and get it done, and same for any further follow up treatments he will need over the next number of years). How easy we forget it seems about the problems that can occur with undertreatment as well.

        • Suzi Q 38

          Like Dr Behar said something like this: “If you need emergency surgery, your surgeon goes home at 5:00.”
          i am not looking forward to it.

      • Suzi Q 38

        I learned from my hysterectomy.
        I went to a teaching hospital, thinking that i could get the best care there. All I wanted was a second opinion.
        Instead, the gyn oncologist did not go through all of my options.
        At the time I was fearful and naive about the possibility of cancer. He did not go through the negatives of having the surgery. He just gave me a surgery date.
        When I got home, the office called me with the news that I had a new surgery date: two weeks earlier!
        I thought, wow, my cancer must be serious!/
        I learned later that maybe I should not have been rushed into this at all, that maybe a few scans were in order first.

        I viewed him as the ultimate decision maker because of where he was working, his specialty (GYN/oncologist) and his credentials.

        As you know, I had a lot of problems after that surgery.

        I no longer allow surgeons to make the decision if I need surgery alone. I enlist the help of my PCP, then another specialist or two. I also will interview several surgeons first, before I decide.

        • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

          Suzi Q, I definitely have to agree that one of the things for helping the shortage is to increase the pay that PCPs get. I read an article yesterday that in Utah they are considering a bill that would add 40 more slots to the Medical School there bringing the number of students in to the program to 122. One of the other things that they are considering along with this is to have it stated that for the first few years after graduating from school that they must practice in Primary Care. Not sure yet if it will be passed in to law or not though.

  • http://www.facebook.com/shirie.leng Shirie Leng

    I’ve been castigated on this site for allegedly dissing primary care docs. But a lot of the comments on this post are correct. The surgeon can fix your hernia but the PMD makes sure that surgery is safe for you, and addresses other health concerns that may contribute to your surgical problem. I’ll tell you for free most surgeons won’t do that.

    • Suzi Q 38

      Your opinion is your opinion. I don’t recall when you have done so.

      Possibly the article about working with NP’s and PA’s….but that needed to be said.

      I will admit that after reading some of the posts and articles/stories;

      I have a better understanding of the physician’s viewpoint.

      When I was younger, I rarely had to see a specialist, except when I had my two children (OB/GYN) and an orthopedic surgeon for my knee (meniscus repair).

      Now I have seen about 8 specialists in the last 2 years.

      1 gyn/oncologist, 1 gastroenterologist, 2 neurologists, 1 MS neurologist (with fellow), 2 neuro spine surgeons (+ 1 fellow spine surgeon) and 1 urologist.

      I even had a medical student and orthopedic neurosurgeon (family friends) give their two cents. They were helpful. They found me a really good neuro for a full work up, and helped me select my neurosurgeon.

      I have had to deal with a lot of egos lately when I try to ask about what my medical problems are, and what their plans were for me.
      some doctors don’t like questions. Some don’t mind.

      When considering surgery on my spine, I needed a couple of opinions. The first surgeon was surprised that I wanted to go get another opinion. He had his PA talk to me about why I felt I needed one, as he was that good.

      To answer mu questions, I needed to not only talk to 2-3 surgeons, but a couple of neurologists as well. My PCP told me flat out that I was on my own on this one, because my condition was so bad that he did not have much knowledge about it. He helped me fill out the referral papers and send them in to the surgeons and neurologists.

  • meyati

    This is so interesting. Everyone has a good point. Talking about patients that use the Internet-that patient is usually proactive, and some doctors don’t like being asked questions, or being told “NO”–politely of course. So much depends on where you live, what type of health plan you have. There are so many variables in personalities-doctor and patient—-I’m grateful for my primary Care Physician. Right now, I’m not too happy with surgeons-