ADVISING THE ADVISORS: THE NEED FOR SPECIALISTS

by Peter J. Nebergall, Ph.D.

When we're sick, when we perceive there is something wrong with our bodies, we head for the doctor. We assume, we have to assume, he/she "knows what is good for us." We want to get well, and we're ready to "do as the doctor ordered."

In the past, we saw the "General Practitioner," and today, in the day of the HMO, many of us see a similar "Primary Care Provider," who we expect to either have the answers, or send us on to someone who does.

The human body is enormously complex. Medicine is not like math; even the basic principles routinely fall to new research. Especially in diabetes research, the pace of change has been tremendous. To expect one individual, however well trained, to have all the answers, to be "up" on the latest research findings on our problem, is unrealistic--but too many folks, both patients and doctors, give medical pronouncements the status of Holy Writ.

Consider all the different things a General Practitioner has to learn. Now consider, once a few years out of medical school, keeping "doctor's hours," how much time doctors have to keep their knowledge current, especially of conditions they see infrequently, such as ramifications of diabetes.

Those who think they know the answer are unlikely to further pursue the question. If a given treatment was the rule in 1975, when Dr. X completed his internship, and he hasn't had occasion to think about it since, given the demands on his time, is it any surprise he orders that treatment in 1997, even though the latest research indicates otherwise? He's the doctor.

So what's the answer? I am calling for a different way of looking at the medical profession, both by patients and by doctors themselves. To expect the single generalist to "have it all," to be the ultimate unimpeachable authority, in this age of explosive change and exponentially increased information availability, is unrealistic, even unfair. We should not expect it of our doctors, and they should not expect it of themselves. There is too much to learn; far too much for one mind, however brilliant, to fully assimilate. We already have our medical specialists; our problem lies with their gatekeepers, the generalists who control our access to them.

Most primary care doctors are careful and conscientious, but the rest of us, the consumers of their product, have placed them on a high pedestal. We ask more of our primary physicians than they can possibly deliver--and it takes a strong, well balanced doctor to admit his/her limitations and say: "No, I don't have the answer, I have to send you on to someone who does." It's very easy, especially with HMO directors watching the bottom line, to instead reach for a treatment modality that was current 20 years ago...

ALL OF US need to accept our doctors' limitations. They dispense knowledge and good judgement, not gospel. In many cases, that is sufficient; but where it is not, sending the patient on to the diabetologist, the nephrologist, or the endocrinologist, can be a matter of life and death. There is a role for the diabetes specialist, just as there is a role for the dietitian and the diabetes educator. Our primary physicians need to stop seeing their/our need for specialist assistance as a personal defeat. We're all on the same side.