The Folly of Self Referral


A lot of Americans think they should be able to make an appointment with a specialist on their own, and view the referral from a primary care provider as an unnecessary roadblock.

This “system” often doesn’t work, because of the way medical specialties are divided up.

If belly pain is due to gallbladder problems you need a general surgeon. If it’s due to pancreas cancer, you need an oncologic surgeon. If the cause is Crohn’s disease, any gastroenterologist will do, but with Sphincter of Oddi problems, you’ll need a gastroenterologist who does ERCPs, and not all of them do. Now, of course, if you’re a woman, that abdominal pain may actually be referred pain from an ovarian cancer, best treated by a GYN-oncology surgeon, which anywhere in Maine means a drive down to Portland.

The other day I saw an older man for a second opinion. He had been through one hand surgery for a small tumor many years ago in Boston, and another unrelated operation for a fracture in Bangor a few years ago. Then, after a non surgical injury, he developed stabbing pains in the same hand. Someone referred him to a neurologist for EMG testing, which was normal, and the man told me that was all the neurologist did, not a full consultation.

The man, who has traditional Medicare and thus the right to see any specialist who accepts Medicare, wanted me to get him in touch with the brilliant Boston hand surgeon. The man told me he wanted a diagnosis and a cure, and not just a bunch of pills, which is what his family doctor had offered him.

“I won’t take gabapentin, I mean, with all those side effects”, the man said emphatically.

“Did anybody suggest the diagnosis of Reflex Sympathetic Dystrophy or Regional Complex Pain Syndrome?” I asked.

“No, is that the name for what I’ve got?”

“I think so”, I told him. “And I don’t think even the most brilliant hand surgeon can help you. Around here, this is a problem that physiatrists, rehabilitation specialists, handle. I think you should see Dr. Paul DeBeck.”

“What would he do?”

“Confirm the diagnosis and probably offer you medication to start.”

The man frowned.

“The list of side effects is only a list of possibilities. It’s published for legal purposes, so you can’t sue the drug company for not warning you”, I explained. “I mean, would you drive a Jeep, or any car, on a public road if you read a document that said your gas tank could explode if you got rear ended, you could hit a moose, you could roll over if you went through a curve too fast, you could slide into a ditch on an icy road or you could get impaled if you drive too close behind a logging truck…”

“Anyway”, I continued, “I think your problem is not surgical, so going all the way to Boston would probably be a big waste of your time. I suggest you ask your doctor for a referral to Dr. DeBeck, right in Bangor. Then he could guide you from there, even if he doesn’t think it is what I think you have. He sees a lot of that type of problem, so he’ll know.”

The same day, I saw a woman with “hip pain”, which turned out to be on the lateral, outer side, of her hip and a little toward the back side. That spelled sciatica from lumbar disc disease. She had wanted an orthopedic referral. But in the northern half of Maine, almost none of the orthopedic surgeons deal with back problems, so an orthopedic referral would have been a terrible waste of time for her.

I sometimes wonder why it is that medical specialties are divided up the way they are; you need to know the diagnosis before knowing what specialist to see. I mean, why isn’t there a belly pain speciality? But, that is why it makes sense to see a generalist first. Plus, we are qualified to treat most cases of the majority of diseases people run into.

Hans Duvefelt is a Swedish-born rural Family Physician in Maine. This post originally appeared on his blog, A Country Doctor Writes, here.

6 replies »

  1. In many cases a well educated intelligent person will skip PCP referral. For the last 3 years I avoided 2 unnecessary procedures including radiation thanks to ignoring my PCP referrals and “wise”advices. Now Internet can give plenty of the newest trends in medicine. Many doctors are so bussy so they do not have time to read and learn this. My urologist still things adjuvant radiation of prostate is golden standard while now, with ultrasensitive PSA tst, earlier salvage radiation is the way to go. I know this but I did not tell him and he still lives in 20th century.

  2. Peter-

    There are excellent PCP’s out there.

    But because we (both Medicare & private insurers)
    pay specialists far more than we pay PCP’s,
    many of our best & brightest med studens just don’t feel that they can become family physicians- even if this is what they truly want to do.

    In Europe, the gap between specialist & PCP income is not nearly as great. This may be one reason why superb doctors like
    Hans Duvefelt, who is from Sweden, practice primary care.

    I’d urge everyone to take at look look at the “Medicare for America” bill that is now in Congress. (Sponsored by Rep. Rosa DeLauro, and backed by presidential candidate Beto O’Rourke, it recognizes the importane of primary care..

    “Medicare For America” is quite different from Bernie Sander’s “Medicare for All” legislation in many ways.

    One way is this: it would pay primary
    care physicians 20% MORE than it pays specialists.
    It pays specialists Medicare rates, but pays primary care physicians 20% more than they earn now, ecognizing that we need more brilliant docs in the front lines of medicine
    providing preventive care, keeping patients out of hospitals,
    and directing them to the right specialists.

  3. William–

    Even well-educated layman are not in a postion to diagnosise themselves.

    I’ve written extensively about heatlhcare and have a Ph.D. from Yale.
    But my degree is not in medicine.

    When a symptom bothers me, I Google the symptom & “Mayo Clinic”
    (among the most reliable websites on line)

    Then I go to my primary care physician, and ask: “Could this possibly be

    To my relief, usually he says “No.”

    “Just try this over-the-counter
    medication and get back to me if it doesn’t help.”
    Or, “I’m going to refer you to a “_____. ” (A specialist I wouldn’t have known I should see).

    When I go to the specialist, sometimes I find that what I learned from
    Mayo Clinc online helps me describe my symptoms more accurately &
    precisely. That may help the specialist diagnose me.

    But I know just enough about medicine to realize that I’m not in a position to diagnose myself.

  4. This is an important discussion. I’m on both sides. I would have no hesitation seeing a competent PCP like Hans to diagnose first, however I’ve had little luck securing a competent PCP. I think overall the system would save money using PCPs as gate keepers, but in the US there is little effort to control patient choice.

    My wife is a nurse with good access to informal consults and I don’t use the system willy-nilly.

  5. Even MDs need a referral from a primary care physician in most cases. Patients would only benefit from following the right course through PCP referral to specialist. Nice article

    Rajat Dhameja, MBBS, MHA

  6. You sound very caring and competent. They are lucky to have you up there.

    So, you believe patients would make too many mistakes in self referral? I’ve wondered about this. Would this mean that these specialists, to whom patients wrongly visit, would glom onto this new patient and wrongly try to fit him into their specialty, and thus waste a lot of health care dollars, or would they simply say “you need to see a ______. Here are a few suggestions.”? Are docs greedy or altruistic on average? Hmmm?

    [ I have a hammer. I’ll treat you with a nail ….vs whoops you came to the wrong guy]

    I had always intuitively thought that patients would usually direct themselves to an appropriate specialist on average. More or less. Maybe it makes a difference in highly educated communities, like Cambridge or Berkeley?

    Thanks for this interesting Take.