Ears

Dave needs a good primary care physician.   His post today reveals his ignorance of the importance of primary care.   This is common in people who are wealthy and/or have "very good" insurance that gives them access to specialty care without referral.

I'm not saying that specialty care is bad -- but I can't even count on my fingers how many times each week I provide services to someone who initially called asking for a referral.  This week's struggle was a dad who called and demanded an emergency referral to a dermatologist for the rash that his daughter had for the past 6 weeks.

"Now .. nothing against you, doctor, but I think that this condition has gotten so bad that we need a specialist."

"I'm happy to refer you to a dermatologist if that turns out to be necessary - but since I have not seen the rash - nor have you even called me about it - it's hard for me to tell the dermatologist why I'm referring the child to him."

"Well you saw her in October for her well-child visit and you said she was fine."

"uuh .. yes .. was she not fine then?"

"Yes she was but now this rash is real bad and we want to make sure it goes away."

"We all want the rash to go away.  I'm happy to see her today and if I can't help you, I will be sure to refer her promptly to the dermatologist."

The child has eczema.  I did a quick google search and found some good handouts to reinforce my counseling and diagnosis.  It's unlikely we'll need to send this kid to derm. 

When I was 15 and living in Cambridge, I scratched my cornea with some sawdust as I was cutting something with a circular saw.  Like Dave, my parents decided that the "experts" would be best to evaluate this and drove me down to the Medical Mecca and I received appropriate treatment for this very common problem. 

So what? 

Like Dave - I could have received appropriate treatment for this problem by any competent primary care physician.   This would have been a better use of the limited healthcare resources that exist in this country.   I treat scratched corneas and impacted cerumen all the time.  So do most primary care physicians.   These propblems are not rocket science - nor do they require the services of specialty care.

The Boston area is hyper-specialized.  There are relatively few primary care physicians and an overabundance of specialists - which is a function of the overabundance of wealthy, educated healthcare consumers, and an abundance of training programs.

While I would agree that the folks at the Mass Eye and Ear Infirmary may be some of the best in the world at what they do - we should only use them when we have conditions that the primary care physicians can't handle.  A good primary care physician would have removed the cerumen from Dave's ears, and would have given him the same lecture about not using q-tips as he received from the specialists.

The disjointed care that people get from a horde of specialists is clearly worse care than the care they get from one primary care physician. 

Yet there remains a perception that the care they provide is better.  We can't combat this work our words - we have to re-educate our patients by providing the comprehensive, care that they deserve. 

IN the context of my patients requesting specialty care - I've been seeing more specialists in MY office.   Caring for another physician is always challening, and initially, this was intimidating to me - yet I've become better at navigating this complex relationship.  Like the otolaryngologist or the ophthalmologist or the CT-surgeon, I am a specialist too - in primary care.