A Severe Voltage Drop in Care ꟷ A Cautionary Tale
- T Michael White MD FACP
- Feb 6
- 2 min read
Updated: Feb 11
By T Michael White MD FACP
“Q: The most powerful force in the universe? A: a charismatic story.” - Albert Einstein
Thursday, February 6, 2025
Dear Mr. President, Honorable Members of Congress and Distinguished Staff and Fine Citizens,
On this journey towards the realization of compassionate, safe, timely, efficient, effective, equitable (just) patient-centered care (C-STEEEP), we must at times articulate what is wrong with our current U.S. Health Care circumstance. Today, let me take a small bite of that apple by telling a story. As the story goes…
In a fine, historic community that takes great pride in its health care, this decision-making cascade is actively in play:
At a major referral center (read — complex patients);
Medical center administration has unilaterally (without physician leadership input and against physician advice) decreed that new office pulmonary consultations will be answered by physician extenders (who usually see follow-up visits); and
In this setting, physician extenders are increasingly only “loosely” supervised by board-certified specialists.
Therefore, a situation exists where brilliant community generalists (for example, family medicine and internal medicine physicians) are referring ill pulmonary patients for senior physician opinion and are being provided with physician extender advice. At best, patients are being referred sideways instead of to enhanced expertise. Clearly, these sideway referrals represent a voltage drop in specialist care.
Should we be alarmed by such a story? Heavens yes! Why? If this were to be the case:
Specialist-level opinion and care is delayed.
The consultation contract is violated.
Physician and patient trust in consultation opinion is eroded.
Uninformed ill patients are expending time (often of the essence), energy and treasure for incomplete care — a significant clinical and ethical issue.
Billing irregularities may be an issue; and importantly
Not even subtly, administration is declaring (and codifying) that physician extender opinion is as good as, as sound as, as informed as — the very same as — senior board-certified physician opinion.
Unless reversed, in one foul swoop, administration is creating an illogical new paradigm that places patients, physicians and U.S. health care on the slippery slope.
Thinking this story through, I am remembering that in my youth, I was a fairly proficient general internist. I often requested pulmonary consultation from master physicians. 90% of the time, they would confirm my (brilliant) diagnosis and treatment ꟷ well done Dr. Mike. However, 10% of the time, they would make an alternative diagnosis and immediately move care in a more appropriate direction. Importantly, I could not predict the 10% as my eyes could not see what my brain did not know. I needed the expertise that training and experience provide the master physician.
Today’s refereeing physicians and their patients need the same expertise.
Yes, stories are only as powerful as their charismatic telling. I hope I have done this important tale justice and brought the implications of my alarming potential concern home to you.
Respectfully submitted,
T Michael White MD
Copy to: We The People (at fixingushealthcare.com)
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