Can Medicine Open Up Its Subspecialist Capacity?
[post_content]
Disclaimer: This article has been automatically aggregated from
A little over a year ago, my patient asked to see a memory specialist, reporting that their family members had noticed some concerning changes regarding their forgetfulness, and they themselves were feeling frustrated with these events.
While their symptoms were mild, they felt that, given a family history of several forms of dementia, they wanted to make sure nothing bad was brewing. I performed a basic relevant history and physical examination, did some routine labs, and ultimately we decided it was worth them seeing a memory disorders specialist.
I placed the referral, and a couple weeks later I got a portal message from the patient: “They told me that I have an appointment with a specialist, but not until November … of 2027.”
The patient said that by that point, they probably will have forgotten why they scheduled an appointment to see a memory disorder specialist.
The problems with limited access and overwhelmed capacity at our institution and across the country have only gotten worse for a variety of reasons.
Since the pandemic, providers are feeling burned out and overwhelmed, leaving the profession in droves.
The demands of scheduling and overbooking and endless portal messages have made people refer out clinical issues that we used to take care of and manage on our own. And patients’ ability to self-schedule a visit with even the most specialized subspecialist, without needing to be screened or evaluated, has led to their schedules being full of patients whom they often shouldn’t even see.
We’ve all seen patients like this, who come in and tell us that they see an endocrinologist for their stable hypothyroidism, a cardiologist for their high cholesterol and well-managed high blood pressure, and a gastroenterologist for their mild reflux and chronic constipation.
Just a few weeks ago, a member of our executive management team reached out to me, saying that they tried to schedule an urgent appointment to see a specialist at our own institution, but there was no availability for at least 6 months. They asked if there was any way I could help.
I sent a few chats in our electronic medical record to see if any of my colleagues had availability and reached out to the scheduling team at the specialty office, all to no avail. Finally, in an effort to try to secure this person an appointment, I sent a gentle email to the chair of the department, apologizing for calling in a favor, and asking if any accommodation could be made.
The chair responded that they’d see what they could do and suggested some folks I could try. But then they relayed that they’d tried to get an appointment in a different department from their own and had been told the same thing — nothing available for 6 months.
Is this any way to run a healthcare system?
I’ve talked before about subspecialists “firing” their patients — folks who really no longer need their services. They should see them, evaluate them, decide the complexity of their care, what needs to be done, and then, if possible, return them to their primary care doctor.
But wait, primary care doctors are overwhelmed…
If we could get these subspecialists to decant these patients back to us, this chronic disease management is our bread and butter. If we had the resources to take care of them, to manage their care, coordinate their care, intensify medication regimens, and do whatever testing is needed, then they may not need to see that specialist anymore, ever again.
One model we’ve been toying with as we think about pulling patients out of specialist clinics (besides screening them better to avoid them winding up there in the first place for simple problems), would be that after the primary subspecialist has evaluated them and decided on a course of action, that they tell the patient that a primary care doctor is going to take care of this from now on. And noting that they will be available if the patient or primary care doctor have any questions, and, if needed, they’ll be able to get them the next level of care in a timely fashion.
Give me, and all the rest of us primary care doctors, the support we need to manage these medical conditions, and we can free up our subspecialists to handle the really tough cases when we really need them.
Give us plenty of nurses, physician assistants, pharmacists, nurse practitioners, care coordinators, and care navigators who can help us bring these patients to a healthier state.
And certainly, new artificial intelligence and algorithm-driven care, focusing on patient’s preferences and optimizing goal-directed medical therapy and interventions, could become a huge part of this.
Every year when the new interns arrive, I anticipate hearing about a case of a patient with chest pain, where the intern suggests we send them to a cardiologist.
It’s always amazing to see their understanding grow as I explain that they can do anything they want for that patient: getting them an echocardiogram, nuclear stress test, cardiac calcium scores and CT cardiac angiography, a long-term event monitor, even sending them directly to cardiac catheterization or electrophysiology studies, without necessarily invoking a long wait to see a cardiologist.
When we need them, we want the subspecialists to be there in a timely manner. When we’re worried about someone, we need help, and it’s a shame if that help isn’t available. Opening up the capacity of subspecialists and giving our patients who really need them access can only make things better.
I’m sure our patients are going to have a hard time giving up their cardiologist, their endocrinologist, their gastroenterologist, but if we can commit to having those doctors be there for them when they need them, then maybe it’s for the best.
for informational purposes only. We do not claim ownership, accuracy, or liability for the content provided. All rights belong to the original publisher.