{"id":7905,"date":"2016-09-26T16:05:47","date_gmt":"2016-09-26T21:05:47","guid":{"rendered":"https:\/\/wholehealthchicago.com\/?p=7905"},"modified":"2021-08-15T22:05:07","modified_gmt":"2021-08-16T03:05:07","slug":"rabbit-hole-medicine-many-specialists-dangerous-health","status":"publish","type":"post","link":"https:\/\/wholehealthchicago.com\/blog\/2016\/09\/26\/rabbit-hole-medicine-many-specialists-dangerous-health","title":{"rendered":"Rabbit-Hole Medicine: Are Too Many Specialists Dangerous To Your Health?"},"content":{"rendered":"\n

Many years ago, shortly after I\u2019d 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\u2019s practice while he took a well-deserved vacation.<\/p>\n\n\n\n

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\u2019s psychiatrist, dermatologist, and cardiologist. The nearest major medical center was 100 miles away, and while he liked talking with the specialists there, he\u2019d refer his patients only when he was stymied by a diagnosis or facing an emergency beyond the scope of his expertise.<\/p>\n\n\n\n

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<\/a>.<\/p>\n\n\n\n

I mention this because recently the physician-only Medscape website conducted a survey entitled \u201cAre You and Your Patients Drowning in Specialists?\u201d<\/p>\n\n\n\n

The answer was a very definite yes<\/strong><\/h3>\n\n\n\n

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\u2019s primary care physician, if the specialist was even aware the patient had one.<\/p>\n\n\n\n

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\u2019s suffering post-traumatic stress triggered by the healthcare system itself.<\/p>\n\n\n\n

The answers to the final question on Medscape\u2019s physician survey are especially chilling: 60% of surveyed physicians felt that specialists either had no impact on the patient\u2019s wellbeing or, worse yet, subjected the patient to a diminished quality of care.<\/p>\n\n\n\n

Because WholeHealth Chicago is geographically close to Chicago\u2019s 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\u2019s an affiliated physician training program. Inexperienced medical students and residents don\u2019t have a lot of self- confidence, so they\u2019ll call in an orthopedist for every backache and a dermatologist for every pimple.<\/p>\n\n\n\n

The domino effect<\/strong><\/h3>\n\n\n\n

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.<\/p>\n\n\n\n

The rheumatologist sees the pimple, murmurs \u201cMight be cancer,\u201d 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\u2019s rushed into emergency surgery with peritonitis<\/a>.<\/p>\n\n\n\n

If she survives, her grateful spouse, CEO of some company, then donates $10 million to Northwestern to name a building after him.<\/p>\n\n\n\n

I hear stories like this far too often. We even have a term for it: Going down the rabbit hole of specialty care.<\/p>\n\n\n\n

Rabbit-hole medicine<\/strong><\/h3>\n\n\n\n

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):<\/p>\n\n\n\n

  1. 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.<\/li>
  2. In the 1950s, British economist C. Northcote Parkinson<\/a> created a series of (very funny) \u201claws.\u201d One was that the demand for a resource expands to match the supply of the resource. You\u2019ll 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).<\/li>
  3. 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?).<\/li><\/ol>\n\n\n\n

    Rather than simply telling a patient, \u201cGo! There\u2019s nothing seriously wrong. Get out of here before you get hurt,\u201d she\u2019s sent to another specialist and then yet another.<\/p>\n\n\n\n

    Uh oh, there she is, making a right turn down one tunnel, a left into another. It\u2019s pitch dark–she can\u2019t turn back and run.<\/p>\n\n\n\n

    Yep, she\u2019s in the rabbit hole.<\/p>\n\n\n\n

    Be well,
    David Edelberg, MD<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"

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