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.
Rabbit-hole medicine
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.
Be well,
David Edelberg, MD
I think primary doctors are a dying breed. They just send you to someone, and on and on and on. Happened to me till I met the last specialist who looked at my blood test and said “Go home, Janis. Go home”.
Janis Becker
As always, I enjoyed your article and the comments. As a retired allergist who carefully listened to all patients. I am a fan of yours, but there is a place for the right specialists, who practice under the right circumstances. There is so much knowledge and so many advances that no doctor can possibly know enough to help every patient, no matter how lofty their intention. Careful referral to sincere, competent, compassionate specialists can be life saving. Communication with the primary care doctor and between all the specialists is essential. Rabbit holes can be avoided.
Robert W. Boxer,M.D.
Dear Dr. Edelberg,
I thought I should add that my story didn’t take place in a large city with large teaching institutions, but a smaller city in Michigan. Any comment at all?
Thumper's Mom
9-27-16
Bravo, well done!
It’s gratifying to know that there are doctors who see the rabbit-hole phenomena and are bold enough to write about it.
I spent the better part of five years traveling progressively deeper into multiple rabbit holes with family members, and to find the reason for my change in health and sleep status. I was told there wasn’t anything wrong with me, at least nothing that a sleeping pill and antidepressant couldn’t cure. Everything would be alright if I just took my medicine. I tried but rejected these; this provoked inferences that I was overly sensitive, over-wrought, or just plain lazy. This was sadly ironic.
My fatigue, night sweats, fur fall and plethora of symptoms drove me dozens of times to the family practice den, where the majority of the time was spent repeating or passing along information that should have been known. I tunneled my way to two other dens only to find another cookie cutter den rabbit who wanted to talk, write a script, or refer, little more than a vending machine in a white coat. When my last appointment ended with a recommendation for an OTC shampoo, I took my complaint before the Grand Rabbit Defender of the medical center. He assured me that my den doctor was one of his best, so I should go to the Mayo rabbits or Cleveland rabbits for help because I surely had something very rare. I disagreed. I had traveled that road before with one of my children, for procedures that I was told could have been done at home, and not in such far-flung fields by such important specialist rabbits. I finally convinced a special rabbit near, to check for cancer again, and it was shortly after this that I was diagnosed with a common kind. Suddenly I found myself in a den inhabited by rabbits of a whole different breed. They seemed anxious to see me, sniffed the air, and smelled like money. They asked me for my story and I told them how I had been declared cancer-free just 6 months before and they could find the paper buried in my growing record. They didn’t seem to hear me; they just wrote something down. These rabbits seemed suspicious and insincere when they told me not to fear because they would take care of everything. But they didn’t. This part of the rabbit hole was dark and vague; the more I asked for guidance, accountability, or options, the darker it became. From the beginning I had asked questions, and more so as time went on, and it had made no difference.
I couldn’t stop them from seeing me as an anxious, Google rabbit of “little papers”; I felt forced to see more and more special rabbits for anything more than standard testing and any help at all. After being parceled out and run around, in the end I was still butchered like piece of meat, literally glued together, and dismissed. The Rabbit Hole is not the biggest problem; it is the attitude of many of the inhabitants there. First and foremost, many don’t believe that you know anything especially about your own body, or that you are telling the truth. Many don’t listen, and observe even less. If you bring in a peer publication from a journal from their field, they often just hand it back to you like it was published by PetPsychic.com. Too many rabbits only want to practice their routine application of medicine, and if the problem is beyond this, they look no further. Many don’t believe that they can be wrong, and when it’s proven, they don’t own it.
I could write a book, but I have to go pack my suitcase for my move to a tiny town in Minnesota where I might find an artful healer.
Thumper’s Mom
Thumper's Mom
Hi John
It was Grand Marais, MN, halfway between Duluth and Thunder Bay in Canada
Hi Suzanne
Yes, sometimes specialists are needed and no doctor could possibly know everything. My issue is a prevalence of medical laziness (“Headache? Let me refer you to a neurologist. Next patient, please”)
Dr E
Hi Doctor EdElbert!
Always appreciate your articlessay and talents. You are the Doctor in the North Woods.
Louis Licastro
My experience has been the opposite. I have had PTSD from physicians who misdiagnosed me with full confidence or spoke with authority on things about which they knew nothing. It is a RARE and elite physician who can know it “all” and admit when s/he doesn’t know. I know only one and I have seen scores and scores of doctors. I would hate to think your words might discourage anyone from seeking new opinions until they found the doctor with the correct diagnosis and treatment.
Suzanne Kush
Hi Dr. Edelberg, Thanks for your always-fascinating posts! In which town in MN did you practice? My daughter Molly (mynameisyeh.com) lives in East Grand Forks!
John Yeh
Oh, what a good article. I went from the HMOs of several decades ago when there was clearly something wrong with me but I couldn’t get a test no matter what (take walks, Dear, and eat fish) to becoming really ill, no doubt as a result of being ignored for years, to seeing up to five different doctors. And I was sick. I didn’t want to run to a bunch of appointments nor could I drive further than 10 minutes on a good day. I felt that post-traumatic stress and so did my adrenal glands. I am now in Mexico hoping to find the kind of doc my grandmother had, who knew that a puffy face and dinishing eyebrows pointed toward a specific test. Apparently, it can still happen here (as well as home visits), but I’m told it’s changing here too because eventually “we do what the U.S. does.” Maybe not this time–articles like yours may just stop, or slow, the process.
Beth
You have just described my experience at Northwestern prior to coming to see you.
Carrie Kelso
YES! Eerily familiar and very frustrating!
Shalini Mendelsohn