Letters To The Editors

Readers speak out on specialist "dumping"

At the conclusion of "Dear Specialist: Please don't dump your job on me" [Mar. 22], you asked readers to share similar experiences we have had. I'm a family practitioner, and I see specialists dumping work on primary care physicians all the time. Orders for physical therapy (so the orthopedist's office won't have to get the referral), disability forms, and, of course, the patients.

My favorite example is the case of the patient who called his surgeon's office at a well-known teaching hospital to complain about pain and fever he was experiencing after abdominal surgery. "Go to your primary care doctor, " he was told. Did I mention that this took place on a Friday—before a long holiday weekend?

To be fair, most of our local specialists don't unload patients for their own convenience, and at the local level that behavior can be dealt with by selective referrals. The real culprits in our area are specialists in a large city nearby. But I appreciated internist Shelly Kruse's article. It assured me that I am not alone.

Nell Nestor, MD
Hendersonville, TN

Shelly Kruse left out my favorite specialist dump line: "Have your family doctor order lab work for you." The patient leaves his office with no idea of what tests to ask for, and seldom does the specialist send any written directive to me.

Larry D. Sander, MD
Orrville, OH

What a depressing article! It sounds like Kruse needs to retire from the practice of medicine. As a family physician, I'm proud that I follow the progress of all my patients who see specialists. That's what family medicine is all about.

Xavier Cantu, MD
Laredo, TX

My chief complaint about specialists is their failure to communicate. When fee-for-service patients wander from specialist to specialist, they invariably return to me with prescriptions for medicines that interact with their regular drugs or exacerbate a condition that no one had bothered to ask about. The most common example: orthopedists who put patients on NSAIDS that worsen their blood pressure, congestive heart failure, or peptic ulcer, or interact with their anticoagulants. If specialists would simply send me a copy of their office notes, I could be alert to this possibility.

The one redeeming feature of gatekeeper plans is the requirement that primary care doctors authorize consultations. At least that gives us the opportunity to send clinical information to the specialist.

Also, may I point out something Kruse failed to mention: By joining a capitation plan, a doctor agrees to perform certain services. Usually, these services include writing prescriptions; the specialist who prescribes a drug should write the prescriptions, including those for physical therapy. Likewise, he should monitor toxicity or response to treatment for non-HMO patients if he performs the same service for HMO patients.

Robert L. Neaderthal, MD
Nashville, TN

Editors Note: The second-prize winner in our 2001 writing contest was L.W. Ghormley's "I was wrong. Medicare is great." We mistakenly identified his article as the third-prize winner in our May 10 issue.

Edited by Liz O'Brien,
Associate Editor

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Letters to the Editors. Medical Economics 2002;12:7.