I argued that being the first contact for patients with new symptoms requires skill and experience. Not everyone agrees on this point.

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

It is a woefully inefficient model of delivering health care. It also exposes patients to the risks of treatment delays, increased costs and inconvenience, and the sometimes irreversible and disastrous consequences of knowledge gaps at the frontline provider.


Seeing a very busy and remunerative specialist when the primary care provider cannot diagnose and manage the condition involves higher costs and in many cases completeness based on the patient having traveled 200 miles for their appointment. you. In such cases, the patents are unlikely to come back for a two week re-check. Therefore, specialists tend to do more in what may be the only visit they have with a patient.


For my patients, seeing a neurologist involves a one-year wait for the out-of-state neurologist doing consultations nearly 160 km from my clinic, or a three to four month wait for an appointment at more. 200 km to Bangor. The situation with rheumatology or dermatology is much the same.

Even if a primary care provider makes a correct referral, patients are at risk of becoming sicker and suffering needlessly because of these delays or, for them, almost insurmountable obstacles to travel.

And the days are gone when a rural medical provider could call specialists in the city several times a month and get free consultations on sensitive cases.

Rural America is almost like a different country in terms of the availability of medical specialists, so less knowledge of the medical front lines is a big deal here. Distance is a neglected health disparity. I even have patients who are reluctant to travel 20 miles to Caribou for an x-ray.


The biggest concern with the mindset you can always refer to 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 writings, I have described the inexplicable phenomenon of clinical instinct and the pride of the beginner Dunning-Kruger effect and also illustrated many common primary care triage situations:

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

Why do so many people consistently belittle the skills 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 designed. It looks like that because of market forces, business strategies, and all that sort of thing.

Hans Duvefelt is a rural family physician born in Sweden in Maine. This article originally appeared on his blog, A Country Doctor Writes, here.

Leave a Reply

Your email address will not be published. Required fields are marked *