Continuing on our discussion about referrals, http://shirahvollmermd.wordpress.com/2010/07/07/the-referral/ and http://shirahvollmermd.wordpress.com/2012/02/27/why-dont-pediatricians-refer-to-child-psychiatrists/, Olivia, seventy-two, presents to me for issues of depression and anxiety. In the course of thorough history taking, we review her medical problems. She is remarkably healthy, absent major medical issues and she is trim and fit and active with a good energy level. We review her treating physicians. Dr. Lesley Lee, a prominent female OBGyn in the community has followed her for years for routine gynecological examinations. Twenty years ago, Dr. Lee noticed on the laboratory tests that her fasting cholesterol was high so Dr. Lee referred her to Dr. Jay, a prominent female cardiologist. “Why did Dr. Lee send you to a cardiologist?” I asked, shocked that Dr. Lee did not send Olivia to a primary care physician. “Well, I don’t know, that is just who she sent me to,” Olivia replies, indicating that she never considered this question before. “Do you have a primary care physician?” I ask, trying to mute my concern for this referral pattern. “No, I did not think I needed one,” Olivia replies, again, seemingly disturbed that I am intruding on her medical issues. Over time, we discuss the importance of primary care and over time, Olivia agrees to go to a primary care doctor that her friend raves about.
I am left to imagine why Dr. Lee sent Olivia to the cardiologist, Dr. Jay. Both physicians are female. Maybe they are friends. Maybe they go to female networking breakfasts. Beyond that, I cannot imagine why a healthy woman, with the only abnormality being an elevated cholesterol should not be referred to a primary care physician, so that diet, exercise, and maybe statins can be discussed in the treatment plan. Clearly a primary care physician can screen for heart disease, diabetes and other metabolic issues. The public health aspect of this referral also concerns me. Dr. Jay as a cardiologist needs to spend her precious time on those who need specialty care, not on those who can be handled by Internists of Family Medicine physicians. Are we, as physicians, not obligated to be concerned about how we use our resources in the best possible way, not just for the patient, but for the population as well? Sometimes, I feel so old-fashioned. Still, old ideas are not necessarily bad ones, as I have said many times.
What can I do? I ask myself. I can try to persuade Olivia to develop a relationship with a primary care doctor. Yep, I did that. Should I call Dr. Lee and discuss my issue with her? I don’t think so. I don’t have a relationship with Dr. Lee and I am not sure I know how to make that call without making her defensive. Should I call Dr. Jay and discuss my issue with her? Again, without a personal relationship, I only stand to make her angry and upset. So, this post serves as my outlet for my discontent. Thanks readers for allowing me to vent.