Accessing medical records. Close up of doctor writing on his clipboard, sitting in his office


"The Specialist"


Many patients are nervous about being treated by their regular doctor and prefer to be seen by a “cardiologist” for any little problem that may seem even remotely heart related. Some patients run to a cardiologist for the slightest chest pain. This exaggerated reliance on specialists is inappropriate, for many reasons.

Most of the time,the primary care doctor is the one who discovers a patient’s health problem. Additional workup is almost always required, along with appropriate treatment. A simple treatment may be all that is required for most patients. Only when there are complicated issues and unusual questions and the primary doctor feels these may fall beyond his or her scope of practice, then referral to a specialist may be appropriate.

Referrals, in general, are tricky. When the referring doctor does not know the specialist and his working style in advance, a patient is likely to encounter one of the following two situations:

1. The Over-Diagnoser: Someover-diagnosing and over-treating specialistsinsist on treating everyone and everything, mostly according to some very misunderstood and overzealous guidelines. Before you know it,the patient may be rushed into procedures and interventions. Some procedures may be invasive and complicated resulting in possible life threatening situations. To make matters worse, a patient who has been through the mills with this type of specialist will likely not agree with or trust their primary care physician any longer.

When a “specialist” recommends complicated workups and extensive procedures, the patient may later look at his or her regular family doctor and silently ask, “Well, who are you to question the specialist’s knowledge and authority. You are no specialist, after all!”

Nothing the primary doctor says or does from this point on will earn the patient’s trust again. Not only will the primary doctor lose authority and credibility, but the patient may continue to pursue unnecessary and sometimes dangerous medical care, leaving the primary doctor entirely in the dark about important discoveries, procedures or medical facts that the primary doctor should know about and have on file.

2. The Under-Diagnoser: This kind of specialist has become more and more common over the last ten to fifteen years. Recently, this kind of specialist almost became the norm in health care. The Under-Diagnoser is typically employed by the local hospital or HMO. No matter how sick or complicated or dangerously life threatening your condition is, the Under-Diagnoser will always tell you, “Don’t worry. Everything is fine,” recommending no further testing or treatments.

Later, when the patient returns to the primary care physician who appropriately sent him or her to the specialist, the referring primary doctor is looked condescendently and with suspicion. The patient may silently say: “All this hoopla for nothing! You made me think I am very sick, and I wasted my time and money going to that specialist and after all, I am just fine. And, by the way, you may not even be the good doctor I thought you were one time.”

Even worse, most patients want to believe that they are not sick, that there is truly no need for further testing or treatments. To want to believe thisis just human nature.

If, at this time, the primary doctor insists that the patient is really sick and that his condition requires further investigation and management, then the patient may presume that the doctor is ignorant at best or an abuser as worst.

The patient may say: “But I’m fine! The cardiologist you referred me to, confirmed that I am fine, so who are you to say any different?” When this happens, then in seconds, all the credibility, trust, and future relationship between the primary doctor and the patient can vanish.

This situation happens far more often than you might think, and I can tell you from firsthand experience that I have lost a good number of patients to death because they were convinced by an Under-Diagnosing specialist that they are “fine” and no action had to be taken further. Sadly, this has become very common as of late, particularly in hospitals.

Sometimes, unbeknownst to the patient and even the referring doctor, the specialist may have his or her hands tied by the hospital, insurance companies, and internal politics when it comes to performing too many procedures of a certain kind. He or she may have no motivation to suggest these procedures or may even be threatened with punishment for doing so, and this is something that you, as a patient, will never be made aware of.

This major problem with both under- and over-diagnosing specialistsis the very reason why your primary care doctor should perform all the pertinent testing and treatments. If many of these tests result in some convincing evidence of a severe and complicated problem and simple treatments fail to solve the problem, then and only then,should the primary doctor carefully refer to a specialist he or she knows to be fair and equitable, someone who does not under- or over-diagnose for any reason.

These “balanced” specialists are few and far between, because there is much pressure on specialists to work as either an Under or an Over Diagnoser. Your best option as a patient is to work with a primary care physician you thoroughly trust, one who will only refer you to a trusted specialist if and when the need arises.