In Treating Patients, Too Many Physician Cooks Spoil the Broth

There are few things in medicine that are clearly the territory of a single subspecialty. Many disorders can be managed by multiple physicians, and depending on one’s training, the management can be very different.

For example, osteoporosis is often diagnosed and managed by primary-care physicians, endocrinologists, rheumatologists, and gynecologists. Occasionally, orthopedists will manage it, too, but that is infrequent. Now although there are guidelines, different doctors have different thresholds for starting pharmacoloigc therapy and frequency of testing, and there are several drugs to choose from.

Diabetes is often managed by internists as well as endocrinologists, and when a woman gets pregnant, then the high-risk OBs step in, too.

Now, there is nothing wrong with specialties overlapping, and given the lack of certain specialists, it’s actually essential. The problem occurs when one patient is being seen by doctors in different fields, and each of them want to manage the same disorder but in different ways.

There are few things that are clearly right or wrong in medicine. There are different ways to manage disorders. But patients can become very confused when one doctor tells them to do one thing, and another tells them to do something else.

When patients approach me with this dilemma, I tell them (time permitting) what the different schools of thought are, the pros and cons of each, and my personal take on it. Then I have them decide what they want to do, and who they want taking care of it. I don’t take it personally if they decide to follow someone else’s advice, but I explain to them, that this means that I will step aside and let someone else deal with said issue. I don’t have the time or energy to repeatedly undo or redo someone else’s work.

Just today, I saw a patient with Type 1 diabetes whom I have known for a couple of years, who recently got pregnant. She is seeing a very hands-on, high-risk OB who wants to manage her diabetes. She seemed unsure. She wanted me to take care of her, but her OB really wanted to keep an eye on things. I told her that I don’t mind either way, but that she needs to pick one otherwise she will get terribly confused. We agreed that she would follow closely with her OB, and let them make insulin adjustments, and that I would see her less frequently during her pregnancy.

Hypertension is managed by nephrologists, cardiologists, internists, and endocrinologists, and given the dozen or so families of blood pressure medications, regimens can be very complicated. This becomes a problem when patients don’t really know what they are on and what their meds are for. That’s when Dr. Kidney prescribes an ACE inhibitor without realizing the patient’s cardiologist already added one to the regimen. I give my patient a list of their meds (or at least the ones I know they are on) most of the time, but that doesn’t mean they read them or that they even keep them. Some keep old ones and never revise them. I had one patient hand me his mother-in-law’s list!

Having electronic medical records that can somehow communicate with one another, will alleviate some of these problems. Until then, I think patient’s need to decide which chef is in charge of each dish.

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