You might assume that you will get better care when you spend extra time and extra money to see a medical specialist. But is that really true?
Not always. Generalists —such as internists, general practitioners and family physicians—have a broader, more holistic view of the patient’s condition and provide integrated care, but they lack the in-depth knowledge that specialists have in their area of medicine. Specialists may provide more fragmented care and order unnecessary tests and more procedures that are risky, studies show.
So when does the benefit of a specialist’s added expertise outweigh the problem of sometimes disjointed medical care and excessive testing?
Rule of thumb: Specialists are generally preferable when a single medical condition that requires expert knowledge dominates all other medical concerns, such as a cardiologist treating an acute heart attack or an oncologist prescribing chemotherapy. Generalists, however, are usually more suitable when multiple chronic conditions, such as hypertension, diabetes and high cholesterol, are present.
How to get the best care for specific medical problems…
Where to start: If you have osteoarthritis, you’ll probably do better in the care of a general physician.
Osteoarthritis, a condition in which the cartilage in joints gradually wears down, often occurs with aging. Most patients do well with basic approaches: Regular exercise, physical therapy, glucosamine supplements and/or the use of naproxen (Aleve) or ibuprofen (Motrin).
See a specialist when: The pain is constant or severe and is not relieved by any of the above treatments. Orthopedists (specialists who often treat arthritis patients) frequently advise joint replacement for arthritic hips, knees and shoulders.
For rheumatoid arthritis: A specialist ( rheumatologist ) is needed. Rheumatoid arthritis is an autoimmune disease that causes widespread swelling and pain in the joints.
Patients frequently are treated with powerful anti-inflammatory and immune-modulating medications, such as etanercept (Enbrel), adalimumab (Humira) or cyclophosphamide. These and other related drugs have serious side effects, including depressed immunity and an increased risk for infection and cancer. They are best administered by a rheumatologist who has experience in their use.
Where to start: A primary care physician. Type 2 diabetes is largely a lifestyle disease caused by obesity and inactivity. It is initially managed with diet, exercise and oral medications, although insulin may be required as the disease progresses. Cardiovascular risk factors, such as high blood pressure, as well as lifestyle factors and blood sugar levels need to be monitored. Because of the comprehensive care that they require, people with type 2 diabetes should optimally be cared for by a generalist.
Diabetes specialists, or diabetologists, endocrinologists who specialize in diabetes, often take a narrow view. For example, they emphasize the importance of lowering blood sugar, frequently with insulin or oral medications.
Overall blood glucose control is monitored by the A1C blood test, which measures average blood sugar levels over the past two to three months. The major health risks for type 2 diabetics are heart disease and stroke, but lowering blood sugar too much (more than a full point in those at high risk) can actually increase risk for heart attack.
See a specialist when: Your A1C level is consistently above 8. (A normal level is below 6.3.) Elevated A1C increases the risk for some diabetes complications, including kidney disease. A specialist might be better able to lower consistently elevated A1C to healthier levels.
For type 1 diabetes: These patients should almost always see a diabetologist. Type 1 diabetes occurs more commonly in young adults and requires insulin shots from the onset. Also, the use of insulin and insulin pumps, which is recommended for type 1 diabetes patients, requires specialized knowledge.
Where to start: People who have had heart attacks always need to see a cardiologist. The first hours (even minutes) after a heart attack are critical, and an emergency room physician will work with a cardiologist. A cardiologist will know what medication should be rapidly administered to minimize long-term damage to the heart and what tests (such as an angiogram) or procedures (such as stenting) need to be ordered. This specialist also will have significant experience prescribing the best drugs for common problems such as dissolving clots and restoring normal heart rhythms.
Most patients who have had a heart attack should see a specialist once or twice a year for the rest of their lives. The patient will be monitored to determine whether treatment such as surgery or stenting is necessary.
See a generalist when: Your condition is stable—that is, you are not having symptoms, such as shortness of breath or heart irregularities. Patients who have fully recovered from a heart attack may want to seek care from an internist or family doctor who has good communication with the cardiologist.
Example: Cardiologists often prescribe multiple medications to aggressively treat heart patients with high LDL “bad” cholesterol by lowering levels from, say, 100 mg/dL to 70 mg/dL. Yet there’s little evidence that reducing LDL that much improves life expectancy. The medication needed to achieve such a low level may increase the risk for muscle pain and memory loss.
Primary care doctors often give a lower dose of the same medication to slightly improve cholesterol and minimize the risk for memory loss and muscle pain.
For heart failure: People with this condition, in which the heart is too weak to efficiently pump blood throughout the body, are best managed jointly by a cardiologist and a generalist. However, people with cardiac risk factors, such as hypertension or elevated cholesterol, but no history of heart attack, are best cared for by a generalist.
Where to start: Almost 20% of patient visits to primary care doctors are for psychiatric problems. Primary care doctors can prescribe antidepressants and antianxiety medications and, if necessary, provide referrals to therapists and support groups. This is appropriate and sufficient for most psychiatric disorders.
See a psychiatrist when: The treatment isn’t working. A psychiatrist will have the knowledge to recommend other medications or medication combinations. Patients with more severe psychiatric problems, such as bipolar disorder or schizophrenia, should always be treated by a psychiatrist.
Where to start: A neurologist should treat anyone who has suffered an acute stroke. If carotid artery disease is the suspected cause of the stroke, a vascular surgeon should be seen to monitor and treat the patient’s risk for blood clots.
An analysis of 10 randomized clinical trials found that patients who were treated in hospital stroke units (with a neurologist on call 24 hours a day) had better survival rates than those who were treated in general hospital wards. Similarly, patients who were treated by neurologists were more likely to maintain brain function than those who were treated by nonspecialists.
See a generalist when: A neurologist has identified and treated all of the possible causes of stroke, such as hypertension and atrial fibrillation. Once a patient has recovered from the stroke itself, a general physician can manage the anticlotting and blood pressure medications.
