Nonsensical recommendations from specialist physicians

Recommendations. Specialists are full of recommendations. Sometimes they’re helpful, even lifesaving. Other times, not so much. I try to make a point of calling ahead and letting them know about special circumstances, but it’s tough getting past their nurses. Then again, even when I do get through to them, I’m never sure I’m getting through to them, if you know what I mean.

Specialist’s recommendation (ortho, seen for fracture):

Frequent falls resulting in head trauma as well as the current injury should be addressed. Recommend workup for balance/equilibrium disturbances.

Do you think the fifth of gin the patient admits to consuming daily may have something to do with that? I called your office and let them know of my concerns. Thanks for the recommendation though.

Cardiology recommendation:

Patient appears to have signs of early dementia.

Actually, he told me his hearing aid was broken on the day of his appointment with you. He’s sharp as a tack when he has it in.

Gastroenterology note:

Patient was non-compliant with colonoscopy prep, medication and dietary instructions.

I told your office manager that this patient has “limited literacy skills.” He can’t read. I’ll bet you handed him a stack of papers containing the bowel prep, directions for the three new meds you gave him, plus detailed dietary information, said, “Any questions?” and left the room before he could say, “Um …?” How compliant would you be if I threw you all that information in, say, hieroglyphics?

I know how hard it is for specialists to admit I may know more than they do about my patients. That may be why my attempts to provide extra information fall so often on deaf ears. But if they listen to me, they may find it easier to make meaningful recommendations.

Now watch me get inundated with comments about dreadful primaries who never call to share the most basic information about the patients they refer, leaving the heroic specialist to save the day. There are bad apples everywhere, and everyone believes their experience is “reality.” These are actual [well, modified for anonymity] letters I’ve gotten from specialists making nonsensical recommendations based on incomplete information. It cuts both ways.

Lucy Hornstein is a family physician who blogs at Musings of a Dinosaur, and is the author of Declarations of a Dinosaur: 10 Laws I’ve Learned as a Family Doctor.

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  • Ron Smith

    Lucy, your post is a classic! One of the best things about being a primary Pediatrician, is that I feel like I’m the guy on the front line. I mean who else is going to be faced with the possibilities that we face? Even after thirty years, I find myself seeing things that I’ve never seen before! What could be more exciting that primary care? Nothing for me.

    Truly these experiences you describe probably make you chuckle like me. I have the same problem with some specialists and I have to ride shotgun for my patients with them sometimes just like I do with the insurance companies.

    Sometimes its more serious and I breathe a sigh of relief for patients. Like the young girl I saw who complained of daily morning headaches for several months some ten years ago. I had to go all the way to the Kaiser physician to get authorization for the brain scan. I think is seemed like a full three minutes before he finally consented after hearing my arguments to get them to approve.

    Later that day we found her brain tumor. I still take care of them today. They won’t go anywhere else. The neurosurgeon I sent them to was one that had taken care of my own daughter Laura.

    They got good care. She survived and is a beautiful young lady today!

    Hang in their! Our patients are worth it!

    Ron Smith, MD

  • Thomas D Guastavino

    As long as you are admitting that it cuts both ways let me point out just a few of the issues that I have had with primary referels;
    1) Primaries that order MRI scans on every patient with knee pain
    2) Primaries that have patients on narcotics for months, sometimes years, refer, then tell the patients that they have to get their narcotic renewals from me
    3) Primaries that attempt to treat fractures, get into trouble, then refer the patient weeks later, when the fracture is much more difficult to manage

    And these issues have been going on for years.

    • buzzkillerjsmith

      Many general docs don’t keep up. Fortunately I can call the ortho and he tells me what to do if I don’t already know. We have tele-radiography in this area.

  • Allie

    We pretend to leave the petty one-upsmanship of premedical students behind when we’re accepted, or of medical students when we match, or of residency when we become attendings, and then . . .

  • ErnieG

    Yes, yes.. I can write all day about nonsensical consult requests from PCP’s. Yes, it cuts both ways. So, there are bad apples everywhere. I did not know that. As I would say.. “move along, there’s nothing here to see”

  • buzzkillerjsmith

    I define a good sub-specialist as one who does what I wanted him to do in the first place. There are few exceptions to this, intractable epilepsy being one. But I know when the pt needs endoscopy and a cardiac cath. If the sub-specialist doesn’t do what I want I refer to someone else in the future.

    I’m sure a lot of family docs and internists feel the same way.

  • rbthe4th2

    Ah thank you! I’ve had the same “honor”.

  • DDP

    Okay, patient here! Wow, did most of you miss the point of the article. From a patients point of view, I find it validating that someone within the profession is willing to honest about what goes on behind my back.

    To Thomas Guastavino, by the time I get to see you for an MRI, I have probably had to return to my primary doctor two or three times and beg for a referral to see a specialist. Now I have some insights into why they may be just as reluctant to give me one and it is not insurance related.

    Believe me when I say it goes both ways. I had a doctor tell me directly that my thyroid issue did not need a specialist. I needed his referral to do so. I finally left his practice and paid cash to see PA. The PA did more for me than the GP even wanted to try and do. I now see a naturopath, who has done more for my return to health then the so called main stream has been able to do. Even this doctor that has the same medical training as an MD has to fight for respect. I would rather pay cash and get results then be shuffled from place to place playing the insurance game while you all bicker.

    I, the patient , is just supposed to gratefully enjoy my time being wasted. For the ten min you may grace me with, I will have probably spent three hours of my day just to get the ten. By the time I get to see a specialist, I may have invested a min of three, but probably the equivalent of a part time job. Do any of you consider what it takes for a patient to even get in to see someone for treatment and when we do we would like to give a rats a** and not treat us all like we are hypochondriacs that just want to waste your time.

    After all, you get paid because you I am your patient. My insurance is not free to me. Why should it then be wasted by you? The article was very insightful, but what is more insightful is the lack of respect shown for the patient while you bicker in the comments.

  • DocEpador

    Well, if doctors TALKED to each other more there would be fewer nonsensical recommendations. Try getting each other on the phone without playing battle of the secretaries (I won’t put my doctor on until yours is on…) and you can see why there are communication breakdowns. I used to call and get calls all the time when I was a subspecialist in the Midwest. Now I am a PCM on the Left Coast, and it is hard to find folks that you can get on the phone, much less to return your call. Or send records of their visit until your office calls three times.