Opinion | Unclogging the Specialist Access Pipeline

As we seek to improve access for our patients, for all the care they need across the spectrum of healthcare, we need to unclog the pipeline in multiple different places.

Just the other day, one of my partners at work walked into my office and said, “So, what’s the best way to quickly get a biopsy for someone with a new thyroid nodule?”

Interestingly, at our institution there are multiple places this can be done. Some at the endocrinology practice do biopsies of thyroid nodules, as do many of the ENT’s, and a few of the head-and-neck surgeons do as well. You can also get it done in interventional radiology.

The problem, however, is knowing who to call and how to get them in, especially when even with these multiple options we are often told that the wait is many months for each of these different locations.

It’s pretty easy for any of us to pick up the phone and call someone, to pull some strings, to call in a favor or two, and we can usually get things done within a day or so. But it shouldn’t have to take all that effort.

Recently, a patient of mine called me and told me she had been trying to get back in to see one of her specialists who she hadn’t seen in a couple of years because the particular condition that this doctor had been following had not been active. She was told the next available appointment for this particular specialist was 6 months from now.

Once again, I was asked to pull some strings and see what I could do.

But wouldn’t it be better if we figured out a way to clean up the schedules, offload the specialists, and improve communication and collaboration, so that everybody was seeing the patients they needed to see, when they needed to see them, and only for as long as they needed to see them?

Take for instance the management of high blood pressure. Or even high cholesterol.

Sometimes when I meet a new patient, they tell me they see a cardiologist, and when I ask them what sort of heart disease they have that requires them to see this kind of specialist, they may tell me they have either high blood pressure or high cholesterol.

Now, in some cases it turns out that this patient has had incredibly difficult to control high blood pressure that multiple primary care doctors have tried for years to get under control, and only with the assistance of a hypertension specialist were they able to get on the right regimen or discover an underlying cause. Or else they have some familial hypercholesterolemia syndrome, unresponsive to standard medications, requiring second and third line agents to get them under control, or even more advanced interventions.

But for the most part, once these things get under control, it’s probably okay for them to be released back into the wild, back to the care of a primary care doctor, where we can continue to manage these problems and follow these medications with appropriate monitoring, with occasional consultation or advice from the specialist, but not tying up their schedule with ongoing follow-up visits for stable issues.

If specialists would be more straightforward with their patients and tell them that they no longer needed to see them, we might clear up some of these access problems.

Sure, no one wants to “fire” a patient from their practice. It’s pretty easy for the specialist to see this particular patient — they know all the right questions to ask and monitoring labs to get done, and what to do when things get tricky or once again spiral out of control. They’ve seen more complications from the management of these conditions, and are better suited when things go off track and need to be brought back into line again.

But even for some of the more complicated cases, once things have smoothed out, calmed down, and gotten under control, it’s possible for a patient to be “fired” from this particular specialist (or maybe “graduated” is a better term?), only to see them again in the future on an as-needed basis.

Sent away, with no hard feelings.

The more we can get these more “routine” cases off the docket of the specialist, the more availability they will have to see the patients with a fresh new problem for which we are reaching out for help.

And maybe it should go both ways.

Maybe after they’ve seen our patients and we’ve gotten an answer from them, we can volunteer the, “We’ve got this, we’ll take it from here,” and say that we will reach out if we have any further questions.

Or we could build a way into the system so they could track the outcomes of this problem through the electronic medical record, with us doing the heavy lifting of refilling medication and tracking clinical response (i.e., blood pressure, cholesterol levels).

The new e-consults in the electronic medical record may offer an incredibly useful tool for this type of collaborative management, helping us get answers about what medicine to try next or what step in testing and interventions we should try, without fully vesting the patient under the care of the specialists.

In this way, they will get paid for their consultation opinion and their expertise, while we still get the information to safely manage the patient moving forward, but no more follow-up with a specialist will be needed, freeing them up to see the next patient.

I have a number of complex patients I’m managing right now with electronic consults as well as fairly regular chats with multiple members of the team, essentially creating a multi-specialty practice built up around the patient right there in the electronic medical record.

As long as this sort of management strategy is okay with the specialists, is okay with the primary care provider, and most importantly, is okay with the patients, this model can go a long way to making sure that every patient has the access they need right when they need it. Without pulling a lot of strings.