It happened again last week. I received a consult note in the mail. My patient had seen the cardiologist for a follow up on cardiac disease. As I perused the assessment and plan, I came across a new entry in the problem list:

“1) Dizziness: refer to neurology”

Because I was opposed to demanding that the cardiologist refer patients back to me for work up, I called the patient’s daughter. I explained that dizziness can have many causes, and only a small percentage of them are neurological. Although I trusted the cardiologist, I asked if she could have her mother come see me first before going to yet another doctor.

The mother and daughter dutifully visited several days later. After a few minutes of questioning and a basic physical exam, the cause of the dizziness became obvious. She was orthostatic and dizzy upon rising. Her blood pressure was 90/60. I cut back on her cardiac medicines and followed up by phone two days later. Like magic, her dizziness was gone.


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I can’t tell you how often this happens. Cardiologists refer my patients to neurologists, neurologists refer them to orthopedists, and orthopedists refer them to ENT. Frequently, if these specialists would just refer back to me, I could take care of the problem much quicker and with less diagnostic testing. It can take months for a patient to get an appointment with a specialist, whereas I could see them much sooner.

I am not saying that I can handle every medical issue, but usually I want the first chance. Because I know the patient, their medical history, and their medications, I am much less likely to disturb the balance of chronic medical issues when treating something new.

But that’s the problem with primary care today. We are not seen anymore as the problem solvers. We have lost a great deal of respect from our colleagues and patients.

In some ways, I feel we have gone the way of the nurse. Much maligned by both physicians and society, nurses continue to toil behind the scenes with great amounts of knowledge and ability. And yet no one recognizes it.

Some days I am the cardiologist’s nurse, some days the neurologist’s, other days the dermatologist’s.