Medical specialist use and over-use

I've been grumbling a lot lately about the over specialization of medicine in this country. There is good evidence that liberal use of specialists does not improve health outcomes, but most certainly increasing costs by comparisons between communities that use specialists heavily and those that rely more on primary care. Obviously, the key issue in the efficient use of specialists is determining when to make a referral. Neurologists don't need to see run of the mill headaches. Gastroenterologists don't need to see every patient with hemorrhoids. In general, a patient should be referred to a specialist when the diagnosis is difficult or uncertain, or if the patient has a set of medical conditions that make treatment particularly complicated.

Yesterday in neurology clinic I saw an 84 year-old man with rheumatoid arthritis, a hiatal hernia (stomach punching through the diaphram), and depression who comes in for an evaluation of his Parkinson's disease symptoms (mostly tremor) at the request of his community neurologist. The patient had a tremor that had worsened over the past 6 months despite medications, so the community neurologist referred him to OHSU for a general neurological evaluation and an evaluation for possible deep brain stimulation. This story is really representative of what I am talking about with fragmented, expensive care that is overly dependent on specialists. After speaking with the patient it was clear that the community neurologist had not increased his dose of anti-Parkinson medicine enough, which is the obvious first step when Parkinson patients begin to progress. Additionally, the patient was on a medicine for the hiatal hernia (this was a past, not a currently active, medical issue) that has a well-know side affect of Parkinson-like symptoms. Nevertheless the OHSU neurologist and neurosurgeon discussed the possibility of deep brain stimulation, which seemed to me utterly inappropriate given that medical therapy had not been remotely optimized and that the patient was on a medication that was likely creating the worsening symptoms. The patient's wife stated during the visit that she was frustrated with all the doctors her husband has seen because none of them really seemed to talk to each other. In short, his problem was not a medical one, but a medical management one. The primary care doctor should have been closely involved with the management of the disease and referral to OHSU. In the doctors at OHSU did not think the patient was a candidate for deep brain stimulation at this point until medical management was improved - thankfully! Nevertheless this illustrates that saying "when you're a hammer everything looks like a nail" - and coming off of family medicine rotation this certainly did not look like a nail.

The medical community - us doctors - are largely responsible for this. We privilege specialists by paying them more and treating their work as more valuable than that done by the generalist (family doctors, pediatricians, and primary care internists). This encourages students and residents to choose specialties, creating a politico-medical brain drain in the generalist community, which widens the economic disparity and promotes over-use of specialist care since there are more providers. Generalists are also to blame for this when they turn medically difficult patients over to a specialists because they are not willing to manage them on their own or at least with a simple consult. This annoys me, especially whey I hear generalists complain that their specialists colleagues are making 2-3x more money.