specialty referral

With the understanding that a medical practice is a small business enterprise,

why would I, as proprietor, want to turn away customers by

referring them elsewhere? Much is written in the lay press and on the

Internet about the importance to patients of finding just the right doctor,

meaning one with whom they will have a good rapport. It is not considered

proper, however, to acknowledge that the physician does not have

the same flexibility of choice when “selecting” his patients. To my dismay,

I must report that not all elderly patients are sweet little old ladies or their

male counterparts. Some older men or women can be quite nasty or rude.

Nothing demoralizes doctor and staff and sours a day of patient care more

than a scene in the office with a belligerent patient. Referral is a professionally

respectable way to unload a difficult, nasty, or noncompliant patient.

On the surface, I am upgrading their care while, practically, I am cleaning

house. This will sound crass and insensitive, but it is important to

acknowledge that not all physician-patient relationships are destined for

success. Specialty referral can defuse a tense situation and offer a divorce

without abandonment.

Specialty referral is becoming, by necessity,

a calculated business decision based on time management

When some patients go from their generalist to a partialist (Bodenheimer

2008, 1064), they have a sense that they have lost more than they

Poly-Doctoring 79

have gained. Patients often return from consultations with a feeling of

detachment.

medical

training teaches young physicians not to think of zebras when they hear

hoof beats. We were taught that common things were common. For the

specialist, however, it is acceptable, if not expected, that he should be the

one to think about zebras. To tell the truth, finding the zebra can be a lot

more exciting, and certainly is more financially rewarding, than managing

the more common maladies of man. In medical school and residency the

more esoteric a doctor’s differential diagnosis (a list of possible diseases

that fi t the symptoms), and the more obscure the right answer, the more

impressed would be his superiors and his colleagues. Unfortunately, the

long-inculcated one-upmanship of medical training and the challenge of

the zebra hunt can suck a patient into a black hole of medical diagnostic

excess from which there is no escape. It begins with the phrase, “I’d like to

obtain a few additional tests.”

a kind of diagnostic arms race. To health care economists, this escalation

is a form of health care value-added tax. The specialist, however,

has not completed his mission until he has searched for zebras.

Remarkable as it may seem, some patients return to me disappointed

and dissatisfi ed when the specialist’s work-up is unrevealing or negative.

I cannot count the number of patients, over the years, who paradoxically

expressed dissatisfaction that the specialist could fi nd nothing wrong!

Since zebras are by defi nition rare, this poses a real problem in customer

satisfaction, as patients often may return from a specialty consultation

with no apparent benefi t, but defi nitely poorer for the experience.