For anyone with their finger on the pulse of American medicine, it is clear that referrals to see specialists as required by many health insurance plans have become a serious problem for doctors and patients alike. Primary care physicians often resent the time that these referrals take out of their day. Many also resent the fact that patients sometimes make appointments for no other reason than to obtain a referral to see a specialist.
From the experienced patient’s perspective, the mandatory health insurance referral infantilizes them, as they generally know what specialist they need to see, and they regard being forced to obtain permission to see a specialist as an egregious encroachment on their sovereignty and bodily autonomy. Moreover, as obtaining these referrals can be arduous, these delays can pose a significant risk to patient health and safety. When my longtime PCP retired at the end of 2025, I had a terribly difficult time finding a new PCP that was able to see me in a timely fashion, was accepting new patients, and was in-network with my plan. Ultimately, I was unable to get a referral for six months, and this is in the heart of New York City! What if I had a heart attack, a serious accident, or was diagnosed with cancer during that time?
While many primary care physicians grapple with an undeniable loss of prestige, they must accept that the specialist revolution is permanent, and that for a growing number of medical problems there is a specialist more qualified to diagnose and treat these conditions than a doctor in primary care. In “Why the primary care system failure forces unnecessary referrals,” Dr. Jordan Cantor points out that primary care was originally intended as a model whereby “a physician who knows the whole patient, coordinates all care, handles 80 percent of issues independently, and knows when to consult specialists for the remaining 20 percent.” The problem is that this paradigm ceased to be applicable in the 21st century, as every year specialists acquire more and more knowledge and have in many respects become autonomous professions in and of themselves. Today, if a primary care physician can treat 20 percent of their patients’ problems while referring out for the other 80 percent, I would consider that to be a respectable ratio.
Many general practitioners fail to acknowledge the fact that medicine has undergone unprecedented changes in recent decades, often refusing to accept that they are simply not as qualified to engage nearly as many conditions as they once were able to treat. Is the primary care physician going to help a patient with a tumor in their neck? What about the patient with glaucoma? Are they going to perform a hemorrhoid banding? Check a patient’s moles for basal cell carcinoma? Treat a patient’s leukemia? Help a marathon runner with chronic foot pain? Write a physical therapy script for chondromalacia patella? Administer immunotherapy for a patient’s melanoma? Evaluate a patient’s options for treating a brain tumor? Perform Mohs surgery? Treat ovarian cancer? There are simply more and more conditions that require specialists, and many general practitioners remain in denial of this reality.
Real physician voices, twice a week
Free, and one click to unsubscribe.
Furthermore, many patients feel that their right to control their own medical decisions is being undermined when they are constantly compelled to come, hat in hand, humbly requesting permission to see specialists that they have often been working with for years. I recently had to ask my GP for a referral to see a gastroenterologist with whom I have been working for a decade.
Experienced patients feel threatened by the power of the PCP to reject referral requests and to potentially force them to work with specialists they do not wish to work with. Primary care physicians that drag their feet on referrals and railroad patients into working with a particular specialist for no other reason than because that specialist might be a friend of theirs are doing what the health insurance companies have long been justifiably accused of doing: delaying, denying, and sabotaging good care.
I have known primary care physicians that are caring and highly intelligent human beings, and it is indisputable that the general practitioner still has an important role to play in medicine, especially with regards to helping patients understand their medical problems and how to live a healthier lifestyle. Nevertheless, patients with a long history of working with specialists become increasingly cognizant of just how complicated each specialty is, and will often see specialists at elite institutions struggling to make a diagnosis, disagreeing with one another, and even making significant mistakes. It is naive to think that a patient who has worked extensively with gastroenterologists, cardiologists, retina specialists, etc., is going to care very much what a primary care physician has to say about medical problems that fall under the purview of these specialties.
Ultimately, the health insurance referral charade humiliates general practitioners and patients alike: the former, by forcing them to spend many hours each week filling out forms as opposed to working directly with patients, and the latter, because they are forced to obtain permission to work with a specialist as if they were a child requesting the use of a hall pass to use the bathroom in an elementary school. This, coupled with the fact that delays in obtaining referrals can lead to critical situations where the patient’s health is potentially jeopardized, underscores the degenerate nature of this profoundly unethical and destructive practice. The argument that in a post-referral America patients would constantly be showing up for doctor’s appointments to see the wrong specialist is ridiculous, as a nurse, physician assistant, or trainee can call prospective patients so as to determine whether they are heading to the appropriate specialist.
Indeed, this frightful state of affairs, so degrading to doctors and patients alike, can only be rectified through the removal of this exasperating roadblock that undermines patient autonomy while incessantly obstructing timely and efficient care.
The author is an anonymous patient advocate.
