Shirah Vollmer MD

The Musings of Dr. Vollmer

The OBGyn Finds High Cholesterol: Now What?

Posted by Dr. Vollmer on February 28, 2012

Continuing on our discussion about referrals, https://shirahvollmermd.wordpress.com/2010/07/07/the-referral/ and https://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.

10 Responses to “The OBGyn Finds High Cholesterol: Now What?”

  1. Jon said

    Your issues with this specific referral make sense. Sadly, so does your analysis of what you can do about it in this specific case. You have already started, albeit in a small way, to discuss the general issue by writing about it here? The next question is: What are the next steps to address the general issue of a referral system in modern health care? I wish you good luck in tackling this problem.

  2. Thanks, Jon for chiming in. Yes, the issue is, of course, complex. There was an era in the 90s when the primary care doctor was forced to be the “gatekeeper” in order to control costs, and although there were merits to this system, many people who needed referrals to specialists were denied. On the other hand, self-referral to specialists can be a poor use of resources. In this case, it was a professional referral to a specialist without the appropriate public health concern factored in. In essence, the current system of self-referral to specialist or inappropriate referral to specialist is weighed against denying people the appropriate care they need. On an individual level, it is better for me, and those I care about to have the ability to self-refer, but on a population level, it is better for the majority if specialty services are reserved for those who really need it. This is one of the complexities of the health care system. What we want for people we care about is different than what we want for the public good. This tension leads to misuse of needed resources, causing others to go without. This is a problem which is not going away any time soon. Thanks again.

  3. Shelly said

    How can you call up Dr. Lee and discuss the issue without breaking confidentiality (in this fictional account)? Obviously she was using a cannon when only a water-pistol was needed, but this smells to me of a good-ol’ girls network and not sound medicine, doesn’t it? If I were you, I’d try to network more so I could get my message across: primary care works.

    • Treating physicians are allowed to communicate with each other, with or without, patient consent, but it is always better to get consent. I am sure Olivia would give me consent, but that, again, is not essential. I like the cannon vs. water pistol analogy. Wonderful! I also like your idea that I can be an ambassador for primary care, as I work in Family Medicine, and I have familiarity with their scope of practice. Thanks!

  4. jo said

    I’m definitely not the typical patient, but as someone with a chronic disease, it’s difficult to find a Primary Care Physician who wants to take the time to really dig into the complexities of my health. I see all of the following specialists: endocrinologist, reproductive endocrinologist, cardiologist, gastroenterologist, ophthalmologist, dermatologist, and hand surgeon. Oh, and a therapist! I have a primary care doc, but I only see her when I’m sick with a virus, have a sore throat, etc. I like her and I think she’s good, but she’s fast and I usually only see her for about 10 minutes. I guess it’s my responsibility to set up longer check-ups to keep her up-to-date, huh? I can see the benefit, but I’m not sure I’m motivated enough to do something about it at the time. In many ways, my CDE (NP and diabetes educator) and my therapist are the ones who keep up with all of my coordinated care. I’m very thankful for them!

    • Hi Jo,
      Thanks for sharing your story. Clearly, each situation is unique, as your chronic disease sounds complicated, then specialty care makes sense.

      • jo said

        I agree that specialty care makes sense for me, but I think it would also be good to have someone who sees the bigger picture. The problem is finding time to find the right doctor and then trying to keep them informed as life progresses. Thanks so much for helping me think about these issues. And after re-reading my last comment, I’m sorry for the doctor-list rant!

        • I am not sure where you live, but I bet there is a bright star out there who can see the big picture. They are hard to find, but they do exist. At least in LA, I know that to be true. Good luck.

          • I agree completely with what Jo said. It took me thirty years to get a diagnosis of a vestibular disorder and that was only because a psychopharmacologist treating me for depression (in a city 150 miles from my home) was curious about why I had been ill for such a long time. He urged me to see a neuro-opthalmologist who spent two hours with me and diagnosed my disorder. Everyone else for thirty years had just assumed I was depressed (which I was because I had been sick for 30 years). Finding a physician who cares enough and has the time to look deeper than the surface has become more and more rare.

            • Shirah said

              Hi Shrinkdocdeb,
              Thank you for sharing your story. I am glad it has a happy ending, but I am sorry that you had to suffer so much.

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