1. Harpham, Wendy S. MD

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The visit is over. Or so you think. Just as you turn to leave the exam room, your patient asks you to check his cholesterol or refill his thyroid meds. Meanwhile your nurse, with her ear pressed against the other side of the door, waits to ask you what to do about a patient who wants to see you-not her PCP-for a run-of-the-mill UTI.

WENDY S. HARPHAM, MD... - Click to enlarge in new windowWENDY S. HARPHAM, MD,is an internist, cancer survivor, author, and mother of three. Her books include

Do you give patients what they want? Or do you insist they see their PCP for problems having nothing to do with cancer? If the latter, brace yourself for patients' anger or disappointment. And don't be surprised if some patients already saw their PCP and were punted to you.


It's an everyday dilemma, one that overlaps with the controversy surrounding who should assume the mantle of patients' post-treatment "survivorship" care. With hope that open discussions can lead us to realistic solutions benefitting both clinicians and patients, I'll share a few thoughts as a survivor and retired internist.


The Patient's Perspective

Why might patients ask you to act as their primary-care physician?


Some patients have no issues with going to their PCP. Their rhetorical "Aren't you my doctor?" reflects their assumption that you can address all their medical issues, much the way many women consider their ob-gyn as "my doctor" for everything.


Other patients need you to provide their primary care. Otherwise they won't get any. Many put up a brave front, not mentioning their financial troubles, used-up sick leave, elder or childcare duties, or lack of transportation. Whatever their reasons, after leaving your office they crumple your prescription to see their PCP and toss it in the trash.


Even when time and money are not issues, doctor visits can be. Patients get burned-out. Some get to a point where they dread another hospital parking lot, more waiting, another exam room and more poking. They're in your office right now. From their perspective, is it such a big deal to check their urine? How is it a problem to add TFTs to your lab slip?


And then there are patients who have put you on a pedestal. You rescued them from the fright of their life and know exactly what their body went through. So, they reason, you always know best what to do. And your nurses and staff with whom they've forged deep healing bonds can comfort them like nobody else. How can PCPs compete with that?


Unfortunately-and I'm not sure how to say this diplomatically-some PCPs are uncomfortable with survivorship. Overtly or subtly, they encourage patients to see you for anything that could be even remotely related to the cancer history.


A Tailored Approach

Obviously, you can't say, "I'm sorry. I'm too busy treating cancer to refill your meds or check your urine." Nor can you suggest, "PCPs are more up-to-date on these matters." So how can you address the problem without jeopardizing patients' confidence in you or their PCP-and do it without falling woefully behind schedule?


As with any conflict, resolution begins with mutual understanding. To this end, find out the "why" behind your patients' requests. If nothing else, you can acknowledge and validate their dilemma as understandable and common.


Then consider the particular circumstances-both patients' and yours-and make a judgment call. Granted, this takes more time and effort than following hard-and-fast rules. And handling the same situation differently for different patients can create problems. But the benefits of a case-by-case approach outweigh the risks.


For one thing, personalizing your response shows compassion. For another, it creates teachable moments. Lastly, tailoring your words and actions to the circumstances can have a positive, healing effect not only on each patient but also on the culture of medicine.


Problem PCPs

If a PCP seems reluctant to evaluate or treat survivors' symptoms, you've got a sticky situation. Knowing you must resist the temptation to send the patient back to the PCP with the message that this is a primary care problem (a response not unlike parents using their children to help fight their battles), what can you do?


You can reach out to your colleagues in primary care, respectful of the unique challenges of their work. By "you" I mean a member of your staff, who can call the PCP's office, explain the situation, and determine if and when the PCP can see the patient.


A less contentious and more practical approach is to take care of the patient's request this one time and dictate a brief note to the patient's PCP. Your synopsis could include a comment about how the patient's cancer history impacts-or doesn't impact-the evaluation, diagnosis and treatment of the issue in question. Depending on your professional relationship, you could invite the PCP to contact you to discuss the case further or if a question comes up. Before closing, you could express your hope of ultimately transitioning all primary care back to the PCP.


I know: It's a lot to ask, which is why I didn't suggest you call the PCP yourself. In the short run, it's probably easier if you fulfill patients' requests. But doing so means you'll deal with the same issue over and over with each patient, postponing the time when you can focus on oncology and leave the primary care to PCPs.


Looking to Tomorrow

Practicing medicine has never been more challenging. The optimal use of diagnostics and therapeutics continues to be a moving target, thanks to progress in science and technology. Survivorship guidelines are lacking. To complicate matters, clinicians' responsibilities are evolving as physician-extenders assume an increasing role in the diagnosis and treatment of disease.


Clinicians can meet these challenges by cultivating a sense of shared mission both across disciplines and from generation to generation. Drawing inspiration from Sir Francis Peabody, we can remind ourselves that a secret of the care of the modern patient is in clinicians caring for each other.