The OBGyn Finds High Cholesterol: Now What?

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.

Why Don’t Pediatricians Refer to Child Psychiatrists?

Neal, thirty-two, a long-term patient of mine is concerned about his five-year old daughter who is having behavior problems in kindergarten. He and his wife are told by the school that she is uncooperative at school and that she needs to be “evaluated.” Neal and Sophie, his wife, take Chelsea, his daughter to Dr. Firth, their highly regarded Westside pediatrician. Dr. Firth, hearing the concerns from the parents, advises Neal and Sophie to take Chelsea to an occupational therapist. The occupational therapist evaluates Chelsea and she tells Neal and Sophie to take Chelsea to an optometrist because she seems to be having “balance issues”. My heart is having palpitations. “Maybe you should consult a child development specialist or a child psychiatrist,” I suggest, hoping that Neal does not feel that I am dismissing Dr. Firth. “Well, I know you see kids,” he says, “but my wife and I associate you with medication and there is no way that we want to put Chelsea on medication.” Again, I pause in distress. “Chelsea needs an evaluation, so it is no way clear whether medication in on the table or not. First thing is first.” I say, reminded that in these days, people only think of child psychiatrists as “medication doctors” and they forget that their expertise is also in assessment. I think about Dr. Firth. Why did he refer Chelsea to an occupational therapist when the report from the teachers was that she was having behavior problems. Should I call the pediatrician and ask him? Of course, I could not do that without both Neal and Sophie’s permission. Why did Dr. Firth not think of referring Chelsea to a child psychiatrist? I really wish I knew the answer to that question. My hunch is that Dr. Firth has a professional relationship with this particular occupational therapist and that he is not aware of the variety of professionals who do  mental health assessments for children, even though he is a well established pediatrician. On the one hand, if what I am suspecting is true, it is unbelievable. On the other hand, if what I am suspecting is true, then Child Psychiatrists have done a poor job of marketing their talents. Maybe both are true.

The Referral

James, a psychotherapist, is seeing Gary, a twenty-four year old patient since he was sixteen. Over the years, he heard about Gary’s significant other, Dan. Gary and Dan had an on-again off-again relationship. Many times, Dan would go with Gary to his appointments, waiting patiently in the waiting room. James heard about Dan from Gary’s point of view, but James never had a conversation with him. Dan calls James and matter-of-factly asks for a referral. “Do you want a man or a woman?” James asks. “A woman,” Dan replies. James is not sure whether to probe further, so he decides not to. He is also not sure whether he should bring up this conversation with Gary. Again, he decides not to. James gives Dan three names; all respected colleagues.

Nine months later, one of the respected colleagues, Nadine, calls James to say “thank you”. James is happy that Dan made the connection; not surprised that it took a long time. Maybe Dan called the other two people and they did not work; maybe Dan took nine months to make the phone call. Nadine suddenly seems to be more friendly with James. James is uncomfortable, not with Nadine’s friendliness, but with the possibility that Nadine is being particularly nice in the hope of getting more referrals from James. James tells himself that he is being cynical. James and Nadine have been colleagues for over ten years. James trusts Nadine; hence the referral. Still, James has a nagging feeling. James also knows that he has no right to know what happens between Dan and Nadine, as this is a private relationship. Nadine knows that too.

Making a referral to a colleague is a layered experience. James’ first concern is to protect his patient Gary. Dan’s phone call does not seem to disrupt that relationship. James’ second concern is to help Dan. James does not know Dan well, but he knows the therapists, and he trusts that his referrals can deal with a variety of issues which might arise in the treatment. James’ third concern is to help out his colleagues. A referral supports a practice; it also reinforces the bond between therapists. On the other hand, if the referral results in disappointment, by the therapist ,the patient, or both, then James is going to get the heat.

Giving and receiving referrals is the backbone of psychotherapy, yet James wonders if there is a framework to think about this process. “Is every interaction with a colleague a show-off event to continue to stay in practice?” James wonders. Perhaps being humble, is actually a mock humility to prove to one’s colleagues that one is able to look at himself; as if to show-off even further. The thought process behind a referral seems to be secretive; a secret even from the person making the referral. Maybe there is a secret, or not so secret wish for reciprocation. Maybe there is a secret, or not so secret wish, for attention from the colleague. James’ nagging feeling continues. He needs to seek consultation; he needs a referral. The irony is not lost on him.