COMMENTARY

Drowning in Specialists

Where Does 'The Buck' Stop in Patient Care?

Julian L. Seifter, MD

Disclosures

August 19, 2016

I'm at the hospital computer, browsing through the electronic medical record (EMR) of my next patient to find my last note from 3 months ago. As I scroll back through one page, then another and another, I see that this patient has had dozens of hospital visits with other physicians from various specialties, subspecialties, and sub-subspecialties.

I am dizzied by all of these names and notes and tests. Mesmerized by the pages of consults, I nod off into a daydream about "The Sorcerer's Apprentice," a segment in Walt Disney's Fantasia based on a story by the German philosopher Goethe.

Julian L. Seifter, MD

In the story, a sorcerer departs from his workshop, leaving his young apprentice behind to carry in water. The apprentice grows tired of lugging the heavy buckets, so he tries on the magician's hat and commands a broom to carry the water for him.

The broom (at least in the Mickey Mouse version) agreeably sprouts arms and takes up the job with gusto. Mickey falls asleep. Meanwhile, the enthusiastic broom creates a rising flood in the workshop. When Mickey wakes up, he panics and chops the broom to pieces, each of which then becomes a new broom carrying in more buckets of water. Eventually, the army of brooms creates a flood that nearly drowns poor Mickey before his master returns and saves him.

The moral of this story: When you summon help, it can overwhelm you.

Calling in the Specialty Troops

Mickey's broom brigade is not unlike the army of specialists and subspecialists called in to treat the patient who innocently visits his primary care doctor. The additional troops are called in for good reason: comorbidities and an accumulation of diagnoses.

The sub-subspecialists are part of the army: You don't just go to a neurologist; you go to a movement disorder specialist, a peripheral nerve specialist, and an electrophysiologist for nerve conduction velocities. You don't just go to an orthopedist; you go to a spine specialist, a hand specialist, and (why not?) a podiatrist.

 
Half a century ago, the job of the internist was primarily to determine whether to refer to a surgeon. Now we have referrals multiplying like brooms with buckets.
 

The advantage in all of this is that you get experts who know their domains in depth. But the sorcerer's apprentice suggests some serious disadvantages: a patient drowning in visits, his life eaten up by his accumulating illnesses with a general sense (often shared by his doctors) that things are spinning out of control.

From the physician's point of view, it's nearly impossible to keep track of all the inputs, and the danger of miscommunication (or no communication) among the various experts grows with each additional consult. Polypharmacy can present another huge problem when no one is minding the general store.

Half a century ago, the job of the internist was primarily to determine whether to refer to a surgeon; otherwise it was all in his purview. Now we have referrals multiplying like brooms with buckets. And we all have a sense that we've gone from a place of comprehensive control of an individual patient's illness(es) to a loss of control and a splintering of responsibility and authority.

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