A classic scenario usually goes like this: primary care doc sends back patient to an orthopedist. The latter reluctantly cannot jump to the knife right away (case management and all) so he orders some physical therapy. A couple of months later, patient comes back still in pain so the orthopod refers him to a pain specialist. The latter schedules a series of spine injections. Patient returns a few months later to the orthopod. Of course he is deemed still not improved but his MRI is inconclusive so he is sent back to the pain doc for a discogram, the results of which usually give the orthopod the license to cut he was waiting for, complements of the grateful pain doc. About 3 months later, the patient with more hardware in his back than the Eiffel Tower, is in even more pain so he gets sent back to the pain doc who rachets the pain meds to a point. Patient is still miserable so a trial of spinal neurostimulator is now warranted, which basically aims at distracting the pain versus eliminating it. Patient is deemed to have passed the trial successfully, whether it is true or not, so now he is referred back to the spine surgeon for permanent implantation of said stimulator (another open procedure under general anesthesia). As this Ping Pong game continues, the doctors and the device manufacturers prosper (or at least the latter) and more GDP is gobbled up by the US healthcare system. Of course the very expensive stimulator usually stops working within a year and occasionally the Ping Pong game includes another match: implantation of a morphine pump. More often the patient now has put in enough time in pain, misery and out-of-work time to qualify for disability income from Social Security...et voila, le tour est joué! as the French would say.
Besides the above duet or trio ensembles, larger ones are common ground in multidisciplinary practices, i.e. quintet or sextet. A patient walks into his generalist complaining of joint pain. After the usual history and physical, he gets referred to the colleague next door who happens to be a rheumatologist. Same scenario, different blood work and now a referral to the orthopedic surgeon partner. Noblesse oblige, the latter has to obtain various imaging tests so the patient is off to the radiologist of the group. God forbid the surgeon smells anything operable, the patient then has to see a cardiologist to clear him for surgery. More tests are done in the practice's laboratories. Often, for "convenience" of course, there is a pharmacy on site and the medications are provided there as they are prescribed by the members of the medical quintet. In this case referrals are indirectly lucrative to the various members of that quintet whom are all partners of the medical corporation. There is clearly NO incentive to cure the patient swiftly and definitively. It would be bad for business and not tolerated by the administrators. The longer the patient is in this loop the better...unless of course his insurance runs out, then his healh is deemed to have improved drastically over night and he is discharged.
Although lawyers for example can refer to each other to their hearts content, doctors are legally barred from doing so by the STARK Laws so. Nonethess the above scenarios seem to be convenient loopholes to get around these laws. Another example of the proverbial toothpaste tube: you press on one end and the paste exits the other end.
If a doctor, mindful of the DO NO HARM clause in the Hippocratic Oath, and maybe also responsible enough to be concerned with the rising healthcare costs, has the temerity to adopt "The buck stops here" approach instead of the "passing the buck" approach by refusing to play the referral game, all hell breaks loose: he will get no referrals from his colleagues because he does not "play ball" and if he manages to survive from word-of-mouth patient referrals because they see in him the real deal, the colleagues' ire and jealousy will increase even more and they will not hesitate to complain about him to the Medical Boards. The latter are usually manned by old timers who grew up in a different era when the medical referral game was the only game in town and the medical specialties were so stringently defined that you practically needed a visa to venture from one to another.
The advent of minimally invasive techniques and technologies did blur those specialty boundaries, especially between conventionally surgical and non-surgical specialties, but the carriers stubbornly call them experimental so as not to pay for them and the Medical Boards maintain a very skewed interpretation of the certificates they award which read unambiguously "License to Practice Medicine and Surgery".
To end on a historical note, Dr Watanabe who invented knee arthroscopy in the mid 1970s was a Japanese rheumatologist. Need I say more!
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