By HANS DUVEFELT

I have made the argument that being the first contact for patients with new symptoms requires skill and experience. That is not something everybody agrees on.

One commenter on my blog expressed the opinion that it is easy to recognize the abnormal or serious and then it is just a matter of making a specialist referral.

That is a terribly inefficient model for health care delivery. It also exposes patients to the risks of delays in treatment, increased cost and inconvenience and the sometimes irreversible and disastrous consequences of knowledge gaps in the frontline provider.

UNNECESSARY SPECIALIST REFERRALS ARE COSTLY

Seeing a high charging, high earning specialist when the primary care provider can’t diagnose and manage the condition involves higher cost and, in many cases, a comprehensiveness that is based on the fact that the patient traveled 200 miles for their appointment. In such cases patents aren’t likely to come back for a two week recheck. Consequently, specialists tend to do more in what may be the only visit they have with a patient.

UNNECESSARY SPECIALIST REFERRALS CREATE TREATMENT DELAYS

For my patients, seeing a neurologist involves a one year wait for the out of state neurologist who does consultations almost 100 miles from my clinic, or a three to four month wait for an appointment more than 200 miles away in Bangor. The situation for rheumatology or dermatology is about the same.

Even if a primary care provider makes a correct referral, patients risk getting sicker and suffering needlessly because of these delays or, for them, nearly insurmountable barriers to travel.

And the days are gone when a rural medical provider could call city specialists several times a month and get free curbside consultations about tricky cases.

Rural America is almost like a different country in terms of the availability of specialist physicians, so less knowledge on the frontlines of medicine is a big deal here. Distance is an overlooked health disparity. I even have patients who hesitate traveling 20 miles to Caribou for an x-ray.

THE DANGER OF NOT KNOWING WHAT YOU DONT KNOW

The biggest concern with the you-can-always-refer mentality is that it actually takes good training and real life experience to know what constitutes an emergency when the clinical signs are subtle and similar to more trivial conditions.

In my own writing I have described the inexplicable phenomenon of clinical instinct and the newbie hubris of the Dunning-Kruger effect and also illustrated many common primary care triage situations:

A rash could be leukemia or idiopathic thrombocytopenic purpura. A sore throat could be glossopharyngeal neuralgia or a retropharyngeal abscess. A blocked ear could be Ramsay-Hunt syndrome, a self-limited serous otitis or sudden sensorineural hearing loss with an abysmal prognosis if not treated immediately with high doses of steroids. A headache or sinus pain could be cancer, and a cough could be a pulmonary embolus or heart failure.

Why are so many people systematically belittling the skills that are needed to be a safe and effective primary care provider? In many other countries, primary care physicians are the backbone of their health care system.

Oh, I almost forgot, our system was never actually designed. It looks the way it does because of market forces, corporate strategies and all those kinds of things.

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