Endos as PCPs   (September 20, 2008)

A few days ago, a friend who has type 2 diabetes contacted me. She was being forced by insurance company mandates to switch physicians, and asked my opinion about whether she should get an endocrinologist not only for her diabetes care, but also to be her primary care physician (PCP).

It's an interesting question. If the same physician could deal with sore throats and sprained thumbs as well as with A1Cs and annual microalbumin checks, it would seem to be an ideal situation. But of course, the real world is not that simple. Otherwise we'd be back to the mythic horse-and-buggy days, where the same superphysician did house calls, assisted at childbirth, treated the kids, fixed broken bones, removed appendices, and for good measure did emergency neurosurgery now and then.

Medicine has advanced, and keeping up with the latest information about diabetes, general endocrinology, and primary care issues is difficult to do. Did I know any endocrinologists who also did primary care? Sure. If the physician has the interest, and time and energy to keep up with the latest information in both endocrinology and primary care issues, more power to them!

Then, there's another problem with us endocrinologists. Some endocrinologists don't really like dealing with diabetes. They'll see people with diabetes, but they're really more interested in more esoteric endocrine disorders, and they may not be completely up-to-date on diabetes care. It's hard for the patient to identify if an endocrinologist falls into this category, but one clue that an endo is indeed interested in diabetes is if the physician has gone to the effort to become a Certified Diabetes Educator. Another way would be to check with diabetes nurses at nearby hospitals: they'll know which endocrinologists are interested in diabetes care.

Many endocrinologists (and other specialists) simply don't want to do primary care. It's a distraction to jump from dealing with diabetes and acromegaly and prolactinomas and hyperthyroidism to deal with strep throats, earaches, rashes, and immunization schedules. As such, it was my approach when I ran my own office that I'd prefer to be a consultant to PCPs for their endocrine cases, and co-manage the care of such patients with the PCP. Of course, there was also an ulterior motive: If I shared the care with the PCP, rather than stealing the case from them, I'd be more likely to obtain more referrals from the PCP in the future. And if a patient came to me and asked if I could be their PCP as well as their endo, I'd bluntly say no, and if they needed a referral to a PCP, I'd advise someone who I already knew worked well with cross-referring patients.

It's a classic choice: does the physician want to know a lot of wide-ranging information to a minimal depth, or would he/she prefer to know one subject in great depth and detail, and let other physicians deal with other subjects. Different strokes for different folks.

For my friend, it'll be her choice of whether to seek a single physician or have several physicians co-manage her care. I can't really identify one choice as automatically being better than the other. I do hope she'll be able to find the care she needs, whether from one physician or several.