Tuesday, January 17, 2017

#8: Your Special Specialist

Dear Dr Tumorific, 

How can I know which doctor at the specialist practice to see?


Dear Jay,

This is a very special question. There are many ways to do this.

For instance, if you would like to use the guidance of the spirits, print out pictures of all the specialists in the specialist practice. Then paste them to a Ouija board. As the paste dries, burn some incense and douse yourself in patchouli oil (at least 5 feet away from the burning incense so as not to light yourself on fire). Clear your mind, and let the spirits of the medico-industrial complex guide the planchette (Ouija piece) to the answer.

If you're less spiritually minded, you could tack that Ouija board to the wall and throw a dart to pick your specialist. Why did you even have a Ouija board in the first place?

Finally, there's the superficial method. If looks can kill, they can also save your life. Peruse the photos. Which one looks most doctorly? Do you prefer red-headed doctors? Are you more comfortable if your cardiologist is ugly? It's all a matter of taste.

But, if you want my real opinion, it's complicated. There are a lot of factors. I am going to interpret the question broadly. I'm not going to talk not just about how to choose a specialist within a given practice, but how to choose any specialist anywhere.

1. This is the most aggravating, but, for many, the most important question to answer: which specialists take your health insurance? More and more, insurance companies are making deals with specific groups of doctors, and if you go to someone outside those groups, you have to pay a higher price, or in some cases, you won't be covered at all. 

Sometimes, your primary care doctor can get special exceptions, but the insurance company will then penalize the primary care doctor's organization financially. This puts primary care docs like me in a tough situation. We would like our patients to go wherever they want to go, but if we ask for too many exceptions, we will get in trouble with our employers. But when we don't think an exception is warranted, we end up being the bad guys by telling our patients they can't get what they want, because, let's face it. almost no one reads their insurance contracts, so the fact they can't see their friends' 'great specialist' comes as a nasty surprise.

2. Next, where is the specialist located? Assuming you're not a medical oddball like me, convenience may be a good way to find a specialist. Especially if you are elderly and have a hard time going places, Dr. Nearby may be the best for the job.

3. Also, which specialist works best with your primary care doctor? Like all primary care docs, I have a few people in each specialty who see almost all of my patient referrals. I know them, like them, and trust them, and I can get ahold of them easily. There are some who will call me within 5 minutes if I text them. I even bug them about random questions when I'm not sending them patients. And if I am sending them a complicated case, I will call and talk to them about the details instead of just sending them a brief written referral request. All else being equal, ease of communication goes a long way towards quality of care.

4. Finally, how special do you need your specialist to be? Aside from intelligence and conscientiousness, the quality of a specialist for a given problem depends largely on how often they see and deal with the problem.

You don't need to go to a medical Mecca to find a gastroenterologist who is an absolute wizard with a colonoscope, and you do not need to go looking far afield for the world's greatest hip replacement surgeon. There are doctors all over the place who do dozens upon dozens of these procedures all the time.

But on the other extreme, you could be like me and have a type of radiation-induced tumor that is rare even among radiation-induced tumors and in a very difficult to reach spot in the bone under my right eye. In 2005, I could have gone to the highly prestigious Wicked Famous Cancer Hospital in my home town and been operated on by very eminent surgeons who had never before worked as a team, much less done my operation ever before. (No kidding! I was going to be their very first case together!) Instead, I chose to go 215 miles away from home to a team of the F'in' Famous Cancer Hospital who did 50 of those surgeries a year. As a result, I still have my right eye. (See http://www.tumoriffic.org/Part%20II.htm, April 17, 2005, The Clash of the Surgeons, or The Eyes Have It!)

The most common way to locate one of these super-specialists is to know somebody who knows somebody, or to ask your doctors, who hopefully will know somebody who knows somebody; I call this the Medical Mafia.

You or your doctor could also look up who is getting NIH grants in that area (
https://projectreporter.nih.gov/reporter.cfm), or research who is publishing articles about their work on similar cases by searching in pubmed (https://www.ncbi.nlm.nih.gov/pubmed/).

So, how to find the right specialist is a very special question. Thanks, Jay, for another good one.

Be well,

Dr. Tumoriffic

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