"I want you to get me a new doctor," she told me, a bit of disgust coming out in the sharp tone in her voice.

"What happened?" I asked.

"He asked me if I was nauseated, and I told him no, I was just vomiting.  Then he asked if I was feeling pain in my stomach, and again I told him no, it was just vomiting.  He then told his nurse to write down nausea and abdominal pain.  When I objected, he just gave me a bad expression and walked out of the room."

I tried to come up with a plausible explanation for his action, but there was none.  "I'm sorry," I said.  "There are a lot of people who come back from him feeling really happy and listened-to.  It's obvious that you saw none of that from him."

"I asked his nurses if he aways acted this way," she continued, "and they just shrugged and told me that he sometimes did."

"I'm happy to send you to a different doctor," I said, shaking my head.

I hate it when this happens.

I send people to specialists for two main reasons:

  • I am not qualified to offer the treatment or procedures the specialist can give.
  • The specialist has far more experience with the problem, and so can offer better care.

But there is one thing I am not doing: giving over care of the patient.  Patients are more than just diseases or problems to be solved.  Patients are more than a single organ system.  It is my job as a PCP to orchestrate and oversee the care my patients get as a whole, including those areas also managed by other physicians.  I am, in essence, borrowing the specialist for their experience and skill to help me take care of my patient.

So when I have a patient come back from an encounter like this one, it not only bothers me for the sake of the patient, I feel a personal sense of being let down by the other doctor.  I need help, and the person I chose to help my patient didn't do the job I need them to do.  Were they just too lazy to listen?  Were they just having a bad day?  Do they understand the question I was asking them to answer?  Did the patient somehow come across in the wrong way?

I am never quite sure for the reasons for these bad experiences, but I hate playing specialist roulette every time I send people to another doctor.  It's not only a waste of time and money, it also undermines the person's trust in me for choosing the specialist, and often hurts their overall view of my profession.  Why bother going to the doctor and pay lots of money only to be patronized, trivialized, or simply ignored, while not seeing their problems get better?

I get the same sinking feeling when I send a patient to the ER.  When I have a person come to the office with problems that need immediate attention, it is often quickest to send them to the emergency room, where they can get labs, x-rays, and specialty consults in a very short period of time.  There are times when I call the ER physician to explain my rationale for sending the patient - especially when I think the reason my not be apparent to someone seeing them for the first time - but there are other times when it is glaringly obvious to me what's going on and what needs to be done.  Yet, again it feels like a game of roulette, never knowing if the doctor will see what I see and do the proper workup, or if the patient will call the next day saying nothing was done in the ER.

From my perspective, the big problem is one of information.  I am working with much more information than the other doctors.  I've often seen the person for many years and in many circumstances, knowing how significant it is when this particular person comes to my office complaining of pain.  I actually had a physician come to me with an acute appendicitis, and even my staff knew how serious a problem it must be for a physician to want to be seen immediately.  I also have all of the previous workup on a problem, a history of previous problems, and I know the family, home, and psychological landscape in which the person lives.  When the person goes to the specialist, the other doctor has only what I send them and what the patient tells them.  What seems obvious to me may not be the same for someone seeing them without my information.  But I do expect them to consider not only the patient's motivation for wanting to be seen, but my motivation for sending them.

It comes down to a single thing: respect.  Patients deserve to be treated with respect, and I am angry when my patients get otherwise.  Beyond that, I deserve to be respected by my colleague for having put thought into my decision to ask for help.  The visit my patient described was not just insulting to her, it was insulting to me. I try to give other doctors the benefit of the doubt, as sometimes personalities don't work together, and everyone has moments where they drop the ball.  Encounters like this one before go into my database when I decide who I will ask when my patients need more than I can offer.  My lack of consults to certain providers, especially after I had been using them in the past, should send a message to them about my opinion of their care.  I've had several physicians ask me why I wasn't sending them as many consults as I was doing previously.  My universal answer is this: my patients had bad experiences at your office.

They are my patients, and I expect them to be treated well.

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