Glorified Triage

The underappreciation of family medicine expertise.

One of my pet peeves is referring a patient to a specialist who then refers the patient to another specialist, assuming I do not have the expertise to manage my patient’s complaint.

In some cases perhaps some new symptom has come up since the time of my initial referral, and the additional referral may be warranted, but in the majority of cases in my experience thus far, it has led to redundant care and excessive visits and testing.

While some specialists are wonderful about looping me into the care plan and referring the patient back to me for new problems - many of which I can address - some are unaware about my scope of practice and view family medicine as glorified triage.

I cannot blame them too much for this, because in many ways primary care in large healthcare systems functions similar to glorified triage. The 10-minute visit incentivizes this. It reduces scope of practice by necessity to get through the day. There is no time to think deeply or broadly about a concern, leading to unnecessary referrals. Or money-making referrals, depending on which side of the equation you are on.

Likewise, some medical schools do not even have family medicine departments. Or if they do, students are discouraged from entering family medicine if they “have potential”. As if what we do is easy. But this is typically only from the mouths of uneducated specialists in my experience. Students rotating through family medicine quickly get the sense of the broad depth and breadth of our everyday work. Many say “I couldn’t do this - there are too many possibilities for every visit. I need a niche field so I can feel like I know everything about it.” They are intimidated by the breadth of the field.

The students have learned what some of the deans have forgotten: family medicine has its own expertise.

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Some estimate primary care physicians can take care of as much as 80% or more of a patient’s health conditions. According to a recent study, family physicians can make over 800 diagnoses. And the more that a family doctor takes care of a patient (termed “comprehensiveness”), the more the patient (or at least the healthcare system) saves.

As a family doctor, I am not a glorified triage pawn.

I am a highly educated, highly skilled physician whose expertise centers on:

1) Knowing my patients on a personal level.

I take the time to get to know their “values, goals and dreams” as one of my mentors likes to say. This can often lead to changes in what would otherwise be the standard plan of care for a patient with a similar condition. We take the time to get to know our patients, and they often respect and appreciate our opinion.

2) Balancing all of their healthcare needs, their values, and the context of their lives.

As family physicians, we do not specialize in an organ system or body part. We specialize in the person in front of us. And we balance their various healthcare needs in light of the big picture of their overall health.

3) Evaluating the undifferentiated complaint.

Rash. Chest pain. Abdominal pain. Joint aches. These are concerns that could lead to many different management approaches, medications or referrals as needed. Not infrequently, I’ve seen patients self-refer, ending up in the wrong specialists office for something their family physician or another specialist could have better managed. While on the surface it might seem like someone with abdominal pain might best be served in a gastroenterology office, it won’t do the patient much good if it’s an abdominal migraine. This is where the broad knowledge and skill set of family medicine comes in - and why we can make over 800 diagnoses.

Family medicine is more than glorified triage.