Navigating Consultations
As a Primary care doctor, I have written a lot of referrals to specialists and have done a lot of before and after conversations only to find the main reason I sent the patient to a specialist was never fully addressed. How you interact with your specialist and prepare for the visit can dramatically change the quality of the consultation. There are a few things that you can do to prepare both with your PCP and on your own to make the most of the visit.
Clarify the Ask: First, make sure you know why your primary doctor is referring you and have access to the critical pieces of health data that are in question. Sometimes it is helpful to have a copy of the referral itself, so you can see what clinical question your doctor asked in the request. Not all specialists read the notes from your doctor either, so having access to this on your phone or laptop can be helpful if they seem puzzled why you are in their office. Not infrequently, I have sent a patient for an abnormal lab result or EKG, attached the items in question to the referral, and the patient comes back after the consult and tells me the specialist did not have a copy of their EKG to review at the time of the appointment and didn’t give them any advice. So bring the EKG, the lab reports, and if possible, the last chart note or have access on your patient portal or device for reference.
Who to Choose: Make sure you are going to the right specialist for your concern. Your PCP can discuss who the best specialists are for the issue of concern. This can be tricky because there may be multiple specialties to choose from for the same issue. Many conditions fall into what I call “territory wars” where multiple specialties take care of different components of one condition or body part, and sometimes multiple specialities can address the same issue. To make it even more complicated, some specialists who are traditionally not in a field that manages a condition may have a special interest or advanced training and locally are the real expert. One example of a territory war condition is MSK injury. Ortho manages breaks and does surgery but not always milder sprains, tendinopathies or undiagnosed pain/dysfunction. For these, you would probably want to see a sports medicine doctor (who could be Ortho or a fellowship trained Family Doc), podiatry if foot or ankle, or a Physical Medicine and Rehabilitation (PM&R) specialist depending on the type and chronicity of the injury. Confusing? It sure is! Sometimes, getting to the right type of specialist is a combination of who is available, who is recommended, and who is in network. But, knowing who to target in researching providers is the first step. If your primary has a personal recommendation, that is usually a pretty good starting point. If they don’t, you can quickly search some of the providers in town and read their professional bios to see what they are best at, or utilize your insurance website if you have one to get a short list of providers in network. A caveat here, these lists are often incomplete and outdated so always fact check!
Questions: Prior to your visit, I recommend writing a short list of must answer questions and your PCP can help prioritize and craft these, they should be in the referral. What if any imaging is best and should I do sooner or later? What is the timeframe I should expect improvement? What med/dose should I be taking? How frequently should I be monitoring bloodwork? What is my risk?
The Story: It really helps if you mentally prep “your story” in advance with as much relevant detail as you can remember. “My palpitations have been noticeable for the past 2-3 years but have been causing me to feel short of breath in the past 2 months.” It doesn’t have to be exact, but ballpark timing with weeks, months, years, seconds, minutes. “The palpitations seem to happen more often than not when I am dehydrated, and they go away within a few minutes when I rest, lay down, or take a cold shower.” The clues that can help categorize severity and build a differential can be subtle, but are often things that are unusual or noticed by you or family/friends. Real world stories or examples help a lot. Your friend comments that you have been pausing on your jog at the halfway point near the meadow with shortness of breath, or you cut exercise short at the gym on days after eating spicy food for lunch at your favorite restaurant. These things benchmark how it is impacting you and also provide context and give the doctor a broader perspective than you might even realize. Maybe its not cardiac but acid reflux or asthma. Take some minutes prior to the visit also to describe what you are feeling, Is it squeezing, is it pressure, is it room spinning? When does it happen? Consider writing down a few days worth of symptoms in a diary with time of day, associations, and description of severity 0/5, 3/5 discomfort. How many seconds/minutes did you feel palpitations, any other symptoms like shortness of breath or chest pain when they are happening? This helps to create some concrete datapoints. Add some vitals to really get more granularity. What was your pulse, what was your blood pressure?
You don’t have to have all the answers but if you can think about it ahead when you aren’t on the spot, you might be able to expand the picture.
Been there, done that: Prepare for the “What have you tried?” This one is very important. Sometimes I have had specialist send patients back to me with a plan we had already tried and failed which was the reason I sent them in the first place! Think about what meds, doses of those meds and duration of treatment you have tried and failed can fast forward past the basic advice to more detailed higher yield recommendations. “I have tried dietary modification by eliminating FODMAP foods for 12 weeks…” “I have been to PT for 6 months with no significant improvement.” “I wore an ankle brace for 4 weeks,” “…took Flonase for a month,” etc. Write it down because it can be hard to recall later.
Photos: Take pictures of medication bottles to show what you are actually taking and include the name dosage and instructions (take 1 tab twice a day). Don’t rely on the med list in the charts being up to date or remembering the difference between a blood pressure pill and a cholesterol pill. Take pictures of rashes, swelling, discoloration. These visual clues always disappear the day of the specialist appointment! When taking pictures, take a few up close and from a distance, with light and near a window/natural light. Make sure it is in focus.
Talk about money. Let the specialist know, “I have met my deductible,” “I am paying cash,” I have a high deductible plan.” While it is unfortunate that we can’t make decisions in a vacuum outside of cost, money and medical debt is very real and there are sometimes cheaper options that are a pretty close second. Your doctor can help navigate that decision with you if they have the big picture.
Summarize: Last but not least, before you leave the specialist’s office, make sure you summarize your to do’s and clarify when you should see them back next. If they don’t think you need to come back, ask them what they want your PCP to do when they take back over, or who else they would recommend you see. Do they think PT would help? Can they put in a referral to someone they recommend or give you a list of names/facilities they trust? The benefit of specialists is not only their expertise, but also their network and experience in helping patients get to the right place.
