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We're all on the same side
Primary physicians and specialists should cooperate,
not compete.
Mr. N, a patient visiting New York from Florida, came to see
me because of headaches. In Florida, his family doctor had prescribed an oral
antibiotic for several months for what he called chronic recurrent sinusitis.
This doctor — whom the patient had been seeing for several years — apparently
was confident that the headaches were a result of the sinus condition.
I wasn't so sure. The sinus expert to whom I sent Mr. N reported no evidence of
a sinus infection and didn't believe the patient needed antibiotics. The
infectious disease expert with whom I shared my office concurred. The
neurologist who treated Mr. N for his headache thought he had a life-threatening
inflammation known as temporal arteritis, and she started him on steroids to
keep him from going blind or having a stroke. The arterial biopsy for temporal
arteritis was equivocal, but the neurologist said this was often the case and
continued treatment.
The patient complained that I was ordering too many tests and sending him to too
many doctors.
Still, he showed a dramatic decrease in his symptoms two weeks after taking the
steroids, and I was able to document an improvement in his inflammation count
(known as erythrocyte sedimentation rate, or ESR). He returned to Florida
relieved.
I left a message for Mr. N's family doctor in Florida, but he didn't return my
call. When I telephoned Mr. N, he sounded edgy and told me his family doctor
didn't believe he needed to see all those so-called experts in New York. This
doctor also apparently thought that there were many intangibles to this
patient's case that only he could know because of the long history together. I
acknowledged the value of this; I merely saw the imperative to communicate the
new findings.
Specialists are helpful in the case of a prolonged illness that doesn't respond
to treatment, but I made it clear to Mr. N that I had only been pinch-hitting
for his regular doctor. "I hope you stay on the steroids," I concluded, and Mr.
N promised that he would. I left another message for the family doctor, but
again he didn't return my call.
Several weeks later Mr. N called me to say that his liver tests were now
abnormal and that his doctor intended to stop the steroids and remove his gall
bladder. "You need to stay on your steroids throughout any operation," I said,
my shaky voice betraying my worry. "Surgery is a stress, and steroid
requirements increase during stress."
Mr. N didn't seem to understand me, and I was faced again with not wanting to
undermine his local care. This time I didn't try to reach his physician. There
was no point in subjecting myself to his dismissal. Luckily, Mr. N got better
before an operation was necessary and left the hospital.
Afterward, he decided that he no longer was happy with his local doctor. I was
able to recommend another doctor with an office nearby. This doctor had similar
training to that of my own and Mr. N's old doctor and was known to be a good
communicator.
Knowing when to call a specialist is at least as important as knowing the answer
yourself, especially in the case of a rare disease.
Mr. N continued steroids under his new doctor's guidance, and his inflammation
was soon controlled. His gall bladder stayed with him as he deleted fats from
his diet. His sinuses never bothered him again, and his headaches disappeared.
Complex cases often require specialists for proper evaluation. A doctor's skills
are multiplied exponentially by communication with specialists, diminished
drastically by isolation and know-it-all care.
The ostrich doctor had his pride, but no one was competing with him or trying to
show him up. He did his patient a disservice by shutting himself off from other
physicians who brought a different perspective to the case.
Mr. N told me that he ultimately switched doctors to enter a world of
cooperative medicine. The growing technology and sophistication of medical
practice these days demand this ongoing exchange. Patients' lives are precious
but must not be hoarded.
Dr. Marc Siegel is an associate professor of medicine at
New York University School of Medicine. He can be reached at
marc@doctorsiegel.com.
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