Many years ago, shortly after I’d finished my residency training, rather than opening a medical office I took a job in a tiny town in northern Minnesota covering a general practitioner’s practice while he took a well-deserved vacation.
He was the sort of doctor who could do just about everything, including attending the births of every soul in town. He also performed surgery and was the community’s psychiatrist, dermatologist, and cardiologist. The nearest major medical center was 100 miles away, and while he liked talking with the specialists there, he’d refer his patients only when he was stymied by a diagnosis or facing an emergency beyond the scope of his expertise.
Because he relied on his own diagnostic skills, he remained mentally very sharp, actively practicing until he finally retired as he approached 90. He then settled down to write his memoirs.
I mention this because recently the physician-only Medscape website conducted a survey entitled “Are You and Your Patients Drowning in Specialists?”
The answer was a very definite yes
Not only are patients seeing too many specialists, but fully 60% of doctors surveyed felt that when a patient was referred to one specialist, more referrals followed, each new specialist ordering tests, drugs, or even surgical procedures while rarely informing the patient’s primary care physician, if the specialist was even aware the patient had one.
When, finally, head bloodied but unbowed, such a patient returns to her original physician, lugging a knapsack of new drugs, a thick wad of test results, and maybe a new surgical scar, she relates what has happened. And her primary care doc realizes she’s suffering post-traumatic stress triggered by the healthcare system itself.
The answers to the final question on Medscape’s physician survey are especially chilling: 60% of surveyed physicians felt that specialists either had no impact on the patient’s wellbeing or, worse yet, subjected the patient to a diminished quality of care.
Because WholeHealth Chicago is geographically close to Chicago’s Northwestern Memorial Hospital, we frequently encounter the phenomenon of specialist overutilization by the physicians there, but it probably occurs at any large medical center, especially when there’s an affiliated physician training program. Inexperienced medical students and residents don’t have a lot of self- confidence, so they’ll call in an orthopedist for every backache and a dermatologist for every pimple.
The domino effect
The consultant orthopedic specialist, who is likely a lowly resident, may hear the patient mention a tingling sensation in her hands and be prompted to call in a neurologist (who might order an MRI and/or spinal tap), a physical therapist, and a rheumatologist.
The rheumatologist sees the pimple, murmurs “Might be cancer,” and calls back the dermatologist for a skin biopsy. Biopsy completed, the wound site becomes infected by hospital-acquired bacteria. The infectious disease team is called in to start some mega antibiotics, but after the patient develops antibiotic-induced diarrhea, a gastroenterologist appears, scheduling a colonoscopy, during which he perforates her colon and she’s rushed into emergency surgery with peritonitis.
If she survives, her grateful spouse, CEO of some company, then donates $10 million to Northwestern to name a building after him.
I hear stories like this far too often. We even have a term for it: Going down the rabbit hole of specialty care.
There are three reasons why rabbit hole-medicine is occurring (and it must be widespread if Medscape is conducting a survey on it among its physician readership):
- Primary care doctors see too many patients in too short a timeframe and the fastest way to move from one to the next and give the patient the illusion that something is being done is to refer her to a specialist.
- In the 1950s, British economist C. Northcote Parkinson created a series of (very funny) “laws.” One was that the demand for a resource expands to match the supply of the resource. You’ll use more of anything if you have a lot of it around (rather like having a large container of mixed nuts in your pantry that you find yourself returning to again and again).
- The GP in the north woods had no specialists at hand, so he relied on his own skills. Northwestern has thousands of specialists and thousands of pieces of expensive diagnostic equipment. Every specialist has her own bevy of tests to order, her own set of surgical procedures. And when it comes to financial rewards, our patient trapped in the rabbit hole can generate several hundred thousand dollars in revenue (and you wonder why Blue Cross cancelled its contract with Northwestern?).
Rather than simply telling a patient, “Go! There’s nothing seriously wrong. Get out of here before you get hurt,” she’s sent to another specialist and then yet another.
Uh oh, there she is, making a right turn down one tunnel, a left into another. It’s pitch dark–she can’t turn back and run.
Yep, she’s in the rabbit hole.
David Edelberg, MD