Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

When patients move beyond the medical home

Fred N. Pelzman, MD
Physician
October 13, 2013
Share
Tweet
Share

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?

ADVERTISEMENT

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. 

Prev

Our words leave the most lasting impression

October 13, 2013 Kevin 3
…
Next

A tiny baby on a big table in a huge OR

October 13, 2013 Kevin 3
…

Tagged as: Primary Care

Post navigation

< Previous Post
Our words leave the most lasting impression
Next Post >
A tiny baby on a big table in a huge OR

ADVERTISEMENT

More by Fred N. Pelzman, MD

  • Why electronic medical records should be standardized

    Fred N. Pelzman, MD
  • Can answers to after hours calls be automated?

    Fred N. Pelzman, MD
  • We have to do better than DNR tattoos

    Fred N. Pelzman, MD

More in Physician

  • Why more doctors are choosing direct care over traditional health care

    Grace Torres-Hodges, DPM, MBA
  • How to handle chronically late patients in your medical practice

    Neil Baum, MD
  • How early meetings and after-hours events penalize physician-mothers

    Samira Jeimy, MD, PhD and Menaka Pai, MD
  • Why medicine must evolve to support modern physicians

    Ryan Nadelson, MD
  • Why listening to parents’ intuition can save lives in pediatric care

    Tokunbo Akande, MD, MPH
  • Finding balance and meaning in medical practice: a holistic approach to professional fulfillment

    Dr. Saad S. Alshohaib
  • Most Popular

  • Past Week

    • Forced voicemail and diagnosis codes are endangering patient access to medications

      Arthur Lazarus, MD, MBA | Meds
    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • The One Big Beautiful Bill and the fragile heart of rural health care

      Holland Haynie, MD | Policy
    • America’s ER crisis: Why the system is collapsing from within

      Kristen Cline, BSN, RN | Conditions
    • Why timing, not surgery, determines patient survival

      Michael Karch, MD | Conditions
    • How early meetings and after-hours events penalize physician-mothers

      Samira Jeimy, MD, PhD and Menaka Pai, MD | Physician
  • Past 6 Months

    • Forced voicemail and diagnosis codes are endangering patient access to medications

      Arthur Lazarus, MD, MBA | Meds
    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • The One Big Beautiful Bill and the fragile heart of rural health care

      Holland Haynie, MD | Policy
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • The hidden health risks in the One Big Beautiful Bill Act

      Trevor Lyford, MPH | Policy
  • Recent Posts

    • Beyond burnout: Understanding the triangle of exhaustion [PODCAST]

      The Podcast by KevinMD | Podcast
    • Facing terminal cancer as a doctor and mother

      Kelly Curtin-Hallinan, DO | Conditions
    • Online eye exams spark legal battle over health care access

      Joshua Windham, JD and Daryl James | Policy
    • FDA delays could end vital treatment for rare disease patients

      G. van Londen, MD | Meds
    • Pharmacists are key to expanding Medicaid access to digital therapeutics

      Amanda Matter | Meds
    • Why ADHD in women requires a new approach [PODCAST]

      The Podcast by KevinMD | Podcast

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

Leave a Comment

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

  • Most Popular

  • Past Week

    • Forced voicemail and diagnosis codes are endangering patient access to medications

      Arthur Lazarus, MD, MBA | Meds
    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • The One Big Beautiful Bill and the fragile heart of rural health care

      Holland Haynie, MD | Policy
    • America’s ER crisis: Why the system is collapsing from within

      Kristen Cline, BSN, RN | Conditions
    • Why timing, not surgery, determines patient survival

      Michael Karch, MD | Conditions
    • How early meetings and after-hours events penalize physician-mothers

      Samira Jeimy, MD, PhD and Menaka Pai, MD | Physician
  • Past 6 Months

    • Forced voicemail and diagnosis codes are endangering patient access to medications

      Arthur Lazarus, MD, MBA | Meds
    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • The One Big Beautiful Bill and the fragile heart of rural health care

      Holland Haynie, MD | Policy
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • The hidden health risks in the One Big Beautiful Bill Act

      Trevor Lyford, MPH | Policy
  • Recent Posts

    • Beyond burnout: Understanding the triangle of exhaustion [PODCAST]

      The Podcast by KevinMD | Podcast
    • Facing terminal cancer as a doctor and mother

      Kelly Curtin-Hallinan, DO | Conditions
    • Online eye exams spark legal battle over health care access

      Joshua Windham, JD and Daryl James | Policy
    • FDA delays could end vital treatment for rare disease patients

      G. van Londen, MD | Meds
    • Pharmacists are key to expanding Medicaid access to digital therapeutics

      Amanda Matter | Meds
    • Why ADHD in women requires a new approach [PODCAST]

      The Podcast by KevinMD | Podcast

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Leave a Comment

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...