A Day in the Life ScenariosHealthcare PolicyHuman Interest


As a family doctor, every day I was tasked with referring patients to specialists. I wasn’t capable of handling every patient’s problem, especially if they involved a surgical diagnosis; so my challenge was to match the patient with the right specialist. I don’t mean, do I send Mrs. Smith to a surgeon or a dermatologist; that’s usually obvious. The task is to chose which of the ten general surgeons on staff is the right one to repair that hernia, or which of the many orthopedic surgeons available should do that hip replacement. Which doctor is the right one for her?

When I started practice, specialists were few. We had only 3 OB-GYN’s, one neurologist, one cardiologist, five orthopedists, one gastroenterologist, and no endocrinologist or oncologist. General surgeons and internists were a bit more plentiful, but not much. Over the years, more and more specialists were trained and admitted to the hospital staff so it became easier to refer patients for special needs. One can imagine how busy you must be in the early years when you’re the only cardiologist on the hospital staff. Every doctor, or at least most doctors, will refer all their patients to you. That makes for long days and a lot of interruptions!

The problem comes when Mrs. Smith decides she doesn’t like or can’t relate to the doctor to whom you’ve sent her. She isn’t comfortable with the care she is receiving. In the old days, she had no choice; either continue with this doctor or go to a different hospital.

Today, with multiple doctors practicing every specialty or sub specialty, the options are more numerous. The family doctor has the capability to choose the specialist he feels matches with your personality and needs, and the patient has the leeway to decide from numerous providers. This decision is one of those intangible, “feels right” kind of things. Will Mrs. Smith like Dr. X? Will Dr. X get along with Mrs. Smith? Will Mrs. Smith get good care from Dr. X?

I remember some family doctors referred everyone to the same general surgeon or to the same orthopedist for everything. They were buddies so backs got scratched. They didn’t take into consideration other personal factors that result in good outcomes and satisfied patients, and often their patients were disgruntled.

Before referring patients to specialists, family doctors take many elements into account to make a decision. Family physicians have the advantage of knowing their patient’s personality and use that knowledge to make appropriate referrals. For my patients, the two most important criteria considered were COMPETENCE and LIKABILITY.

By Competence I mean is the doctor good at what he does. You only learn that over time by observing how patients fare after they’re operated on or treated by that doctor. If a lot of Dr. X’s patients have complications, get wound infections, or take longer than normal to recover, you might want to refer to a different surgeon. If Dr. Y’s total hip replacement patients have a high rate of post-op problems or frequent joint dislocations, refer to a better orthopedist.

Another competence issue is the determination of an accurate diagnosis and the prescribing of standard, accepted, and recommended treatments. If Dr. X fails to recognize obvious signs and symptoms of a problem or prescribes some inappropriate drug or unusual procedure, I would refer to a physician who I know follows standard protocol.

By Likability I mean is Dr. X a nice person. When you repeatedly get reports from patients how Dr. X was rude to them, abrupt in communication, and didn’t listen, I referred to a different doctor. I referred most patients to doctors who I knew were nice people, and who I personally liked—Doctors who treated me as an equal, weren’t arrogant, communicated well with me and patients, and were caring people. It upset me when I had to apologize to patients for the manner in which Dr. X treated them. If I had to do that once or twice, I referred to someone else. A big part of a patient’s successful outcome is the trust and confidence built into the doctor-patient relationship. If Mrs. Smith dreads Dr. X’s visits, things aren’t going to go well.

Thus, I tried to select the right surgeon for the right patient. In each specialty, I developed a handful of individuals I referred to almost exclusively. There were some I referred to rarely because of patient dissatisfaction or because I thought they weren’t as good as some others. I wanted the best for my patients and tried hard to achieve that goal. Meshing personalities is very important but must be coupled with high quality care.

Two specialty areas where the doctor-patient relationship is particularly important are oncology (cancer care) and obstetrics. When one has Stage 4 cancer, you want a doctor who cares, listens, and communicates well. Trust and confidence are very important in what are usually a patient’s last days. In the highly lawsuit-prone practice of obstetrics, rapport and concern mean everything. So often, a patient will choose one physician in a group practice as her OB doctor. She will see him for every prenatal visit, but when delivery time comes, he is not on call and a partner, with whom the patient has not developed rapport, and may not like, delivers the baby. This sets up mistrust and uncertainty on the patient’s part, and any minor glitch or complication gets amplified and may trigger a lawsuit. This OB dilemma is one I saw often.

On occasion, the decision to refer was out of my hands. For example, Mrs. X breaks her hip, is taken by ambulance to the ER, and is referred to Dr. Anybody by the ER doc before I’m consulted. That scenario could be touchy but was manageable. It didn’t happen often, but when it did, I was always supportive of the specialist.

Competence and likability were the characteristics I looked for in specialists. I always sought out the best specialist in each area and referred to them as exclusively as possible. As a result, my patients had low rates of complications and rarely bad outcomes, and I received very few complaints about specialists. Knowing you’re sending patients to someone they will like and who will take good care of them means a lot to the patient and makes the doctor’s life much easier.

Reference: Personal experience during 40 years of clinical practice.

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