Even in its purest form, in the most perfect patient-centered medical home we can create, patients will sometimes need to move beyond the confines of primary care.
Each of us in primary care has a point that we choose not to venture beyond, into the realm of subspecialty medicine where we lack the experience and tools and support to fully implement complete care for patients with these particular problems.
It may be patients with neurodegenerative diseases or seizures who need neurological care, cardiac patients who need pacemakers and antiarrhythmics, or patients with psychological problems that need more than simple counseling and simple medication management.
For each of these areas, we collect around us a group of specialists or subspecialists we work with to provide the care that’s needed.
But frustrations — for our patients and for ourselves — crop up when this care is provided outside the best-faith efforts of a patient centered-medical home, without thought to the patient as a whole.
This brings to mind the story of the blind wise men who are led into a room to examine an elephant, and asked to tell the king what they find. Each wise man touches a different part of the elephant: the trunk, an ear, a tusk, a leg, a tail, his massive side.
And each wise man in his turn tells the king what he has found: a snake, a fan, a pipe, a pillar, a rope, a wall.
It’s not that the wise men aren’t wise, it’s just that they can’t see the whole elephant.
That is, thankfully, our job in primary care — to see the whole elephant.
And nothing starts my day off with a small flicker of pain like seeing that urgent, high-priority, red-flagged message in my in-basket: Patient is in the “blank” (insert name of subspecialist field) office and needs a referral faxed immediately so he can be seen.
What does such a referral accomplish? Does it help us coordinate care, or prevent unnecessary testing by subspecialists, or really help me serve as some sort of gatekeeper?
The patient called on their own and made an appointment to see a dermatologist for some rash, a podiatrist for some foot pain, a cardiologist for some chest pain. They are already there, they have already taken time out of their day to get there, and denying them the referral seems unreasonable.
But am I really practicing up to my medical license by entering in our electronic health record a blank podiatry referral, with a diagnosis of “foot pain,” and indicating how many visits are allowed along with other useless administrative details they need so that the insurance company will pay the bill?
And what’s the likelihood of that subspecialist communicating back with me, even sending their consult letter back? It’s exceedingly low, unless we share an electronic health record.
It’s clear there needs to be better planning, better communication, and better coordination. How do we bring this about? We can beg and scream, insist, cajole, demand, but little seems to help.
Our patients return to us for follow-up visits after having seen multiple subspecialists since they last saw us, with little communication back to us. We are left to spend our time on the phone, trying to get someone to fax us their records, calling the pharmacy to try to figure out what medicines were given and what was going on in the mind of the subspecialists.
At the end of the day, we sometimes find that the patient has been prescribed all manner of medications, ones that they have tried in the past, ones they refused to take, or ones that may interact with one of their other medications the subspecialist did not know they take.
The patient, in fact, may not have revealed details about their past medical history that could have been useful, nay even critical, to the decision-making of the subspecialist.
One potential solution may be the use of the extended patient-centered medical home care team, allowing patients to have ongoing communication with their healthcare team in between their visits. These individuals can help patients navigate the tricky world of the subspecialist visit, ensuring that high quality and patient-centered care is delivered.
They can help see that the patient is treated right by the subspecialist when the patient is there, offering important data and insights to the new provider that may be critical to a positive outcome.
As part of pre-visit planning, care coordinators and support staff will ensure that all information from visits of patients seen by other providers in the interim has been collected and brought to the primary team, to allow us to bring it all into focus, to put it in the context the patient’s ultimate health.
To help us all see the elephant in the room for what it truly is, an elephant in all its elephanty splendor.
Fred N. Pelzman is an associate professor of medicine, New York Presbyterian Hospital and associate director, Weill Cornell Internal Medicine Associates, New York City, NY. He blogs at Building the Patient-Centered Medical Home.
