I remember seeing so many charts in my career on which the well-meaning emergency room physician wrote the following:  “Follow up with your primary care doctor.”  Or, if they didn’t have one, “Follow up in one week with a primary care doctor.”  I laughed to myself.  Usually, the people we say that to have either no insurance, inadequate insurance or inadequate motivation to even call the persons to whom we may refer them.  Or they find themselves in an area with next to no primary care physicians to begin with.  Call all you want. It won’t happen.

The same thing is now happening as administrators, evaluators, educators, attorneys and law enforcement personnel are scrambling to keep up with changes in narcotic prescribing.  The new mantra is that patients with chronic pain should see their primary care physician; or a “pain specialist.” I put that in quotation marks because as in the case of so many specialties, it can be dang hard to find one of those pain doctors. (The real kind, not the storefront drug dealer type.) We see it also in emergency physicians and ED policies that say, for instance, “We don’t give narcotics for toothaches.  See a dentist this week.”  Again, without cash in hand, and even with it, that may not happen so easily.  It’s also a little short sighted.  Anyone who has had a severe toothache will tell you that sometimes narcotics do, in fact, have a role.

And what about mental health?  Every time we have a mass shooting, a new report of epidemic depression and anxiety, bullying or any other issue that touches on mental health, some wise person says the obvious.  “People need to be referred to psychiatrists or counselors.”  Brilliant idea!  Except psychiatrists can be elusive.  Their care may be costly and their availability, depending on geography, very limited.  Ditto for counselors and psychologists.

It’s great to say, “You should go to this doctor or that doctor.”  But the fact is, for some folks the ER is about as far as they can get … even when they’re especially motivated.  Whether it’s because of money, facilities, professional politics or location, often the referral simply won’t succeed.

I’d like for people to see specialists when they need them, or even primary care physicians!  Largely because we can only do so much in the emergency department.  But I’m realistic enough to know that many, oh so many, of the referrals we suggest never get done.

So let’s apply a little reality to our referrals.  And do our best to help our patients navigate an increasingly laborious and complex health care system.

Edwin Leap is an emergency physician who blogs at edwinleap.com and is the author of the Practice Test and Life in Emergistan. 

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