A recent unintentional severe insult:  Family Doctors are Gatekeepers.

I was recently at a dinner where a professional triathlete was speaking.  After the dinner and his speech, I introduced myself and was extremely delighted to meet a professional athlete in a sport that I enjoy.  We began chatting, and he quickly discovered that I was a family doctor.  He then continued to casually talk about the family doctor profession:  “…you guys are the gatekeepers.  If someone comes in for a skin condition, you refer them to a Dermatologist.  If they hurt their knee, you send them to an orthopedic surgeon.  Then, if someone has diabetes, they go see an endocrinologist.  You guys really have a unique position in the healthcare system.”

44309_a_zmWham! Bang! Pow!  I heard those sounds like an old batman episode rattle in my head.

He single-handedly dealt the worst insult that I have heard in a long time, probably since high school.  He basically told me that I do not know anything, and I just direct patients to different doctors like a traffic light.  Unfortunately, I think much of the American general public thinks that this statement is true.  In fact, they may not even understand why it is an insult.  Therefore, I decided to blog about this insult.

Let’s break it down.

Your family doctor is not your gatekeeper.

Let’s investigate what a Gatekeeper insinuates.  By calling me a gatekeeper, you have basically told me that I am a stepping-stone that is in the path of getting to where you want.  No, actually, it is worse than that.  You are saying that I am in the way of getting to where you want because you are saying that I am the gate that you must open, shove aside, and then walk through to get to your destination.

In case you do not know this, your family doctor has gone through years of medical school, residency training, and post-graduate medical education classes in order to stay current and sharp in their medical knowledge.  For you to think that we cannot help with your medical problem is absurd.  You should never walk into a family doctor’s office and say, “I am here to get a referral to ______.”  It is plain insulting. If you are an American that thinks they need a specialist for every tissue that they have, you need to find another doctor.

Although the healthcare debacle rages on in our country, I want to assure you that no one is pulling strings to tell doctors whether or not they can refer to specialists.  There is not a benefit or deduction for referring or not referring patients.  The reason I choose not to refer patients to specialists for every problem is because I know my abilities and my spectrum of knowledge.  If a condition lands outside of that spectrum, I will quickly refer you to the correct specialist.

Let me ask you a simple question.  Which patient do you think is getting better care?

Patient 1:  A patient who has a cardiologist for his cholesterol problem, a pulmonologist for his asthma, a psychiatrist for his depression, and a gastroenterologist for his heartburn?

Patient 2:  A patient who is getting his cholesterol, asthma, depression, and heartburn managed by a confident and skilled family doctor who is checking for medication interactions and long-term affects of all of the medications that the doctor is prescribing.

Let me tell you that I have seen first hand patients that are seeing multiple specialists without adequate care.  Moreover, each specialist may not even look at the medications that you are taking unless it is one they prescribed.  How many times have you been to a specialist where they did not even take the time to find out which medications that you are actually taking?

Ever heard of a psychiatrist giving trazadone for sleep, then the patient seeing an urologist because they can’t urinate?  Then, the patient is prescribed Flomax for help with urination.  Now, it turns out that the patient is getting a second medication that is treating a side effect of the first medication.

Rule 1 of being a physician:  Do not use a medication to treat the side effect of another medication (unless the initial medication is truly needed and irreplaceable).

Here is another real life story:  A patient was started on amlodipine for high blood pressure.  Then, the patient was referred to a nephrologist for leg swelling (caused by amlodipine).  The Nephrologist gave him Lasix to treat the leg swelling.  Later, the same patient was sent to a cardiologist because of a fast heart rate (caused by dehydration from Lasix).  The cardiologist gave the patient metoprolol to slow down the heart rate.  Now, the patient is taking 3 medications for 1 problem and 2 side effects.  This is poor quality healthcare.

If you have too many doctors involved in your care without a family doctor overlooking your entire care, you are bound to end up in trouble.

So far, this blog has been beating up on specialists.  Am I saying that all specialists are bad?  Of course not, I refer to specialists all the time.  But, I am saying that you do not need a specialist for every individual problem that you have.  Your blood pressure should be treated by your family doctor without a referral to a cardiologist.  Your acne should be treated by your family doctor without a dermatologist.
If you are coming to me to be your gatekeeper, then you should find another doctor.   My goal is to be the smartest, best doctor that you have ever met, and I will do everything in my power to treat you to the best of my capability.  I will study, Google, and read books in order to help determine the latest, greatest, and best treatment and diagnostic tests that I need to help you conquer your medical problems and goals.  I promise that I will refer you to a specialist at the appropriate time when it is needed or indicated, especially if I cannot diagnose or improve your condition.  But, you have to give me the chance, and you have to trust me.

Your family doctor can handle many more problems than you think.  Give them a try.  If they cannot, then maybe it is time to look for a new one.  Being a good family doctor, in my obviously biased opinion, is the hardest type of doctor to be.  It is the only physician that treats as we say, “Womb to Tomb.”  The family doctor is taught how to care for children, adolescents, adults, elderly, and pregnant women.  We are the only doctors that rotate through almost every specialty, and we are even heavily trained in mental health (psychiatry).
A family doctor is the original doctor.  I want you to think about 50 years before specialists were on every street corner.  If you were living on a farm in rural Texas, and you got sick.  You would call the doctor who would make a house call.  If your wife were to have a baby, you would call the doctor to help deliver the baby.  And, if your baby ran a fever, you would call that same doctor to evaluate the child.  If your elderly grandmother had a heart attack, you would see that same doctor caring for her in the hospital.  This doctor had no other title besides “doctor,” but he was what is now called a Family Doctor.  He did not have the title family doctor because he was the ONLY doctor.  He was responsible for knowing how to care for any aged human being regardless of gender.  The family doctor is not different from that doctor 50 years ago; we just have a different name.

Why did I decide to become a family doctor?

1)     The family doctor is the only field where I have the privilege of caring for all age groups.

2)     The family doctor is the only field where I get to care for ALL medical problems.  In fact, you could have any complaint or problem, and we would be able to see you in our office.  I would be able to give you a reasonable diagnosis and start treatment.

3)     The family doctor gets to establish long-term relationships and care for families that span multiple generations.

4)     The family doctor holds an immense amount of responsibility because we are charged with maintaining wellness and preventing illness.  We are the first to be blamed for missing that dreadful early sign of disease that should not have been missed.  Unfortunately, hindsight is always 20/20.

5)     The family doctor is the one who follows you throughout life’s tragedies and triumphs.

6)     The family doctor is the one who will be with you as you battle weight gain, fight pneumonia, and wage war against cancer.  Your family doctor will be the one to hold your hand, cry with you, and treat you until your very last breath.

Do you have a good family doctor?  If not, maybe it is time to find one.  I invite you to grow with me, learn with me, and age with me.  Life is full of adventure – let’s enjoy the ride!