This wouldn’t be so confusing if I had thought about what specialists and general practitioners are each supposed to do. But I have no such a priori understanding. I send a patient to a specialist, and my thought is something like this:
“Gee, I hope they pursue a self-limited course of diagnosis and treatment based on the clinical question I have in mind!”
And the patient, on the other hand, thinks something like:
“Dr. Berger wants Dr. Gutskener to figure out why my belly hurts.”
Dr. Gutskener, on the other hand, possesses a treasure of expertise around the gastrointestinal tract, and doesn’t generally feel his role to be limited in the sense Dr. Berger (me) is thinking of. He takes “limited” to mean “within a given subspecialty” – he does GI, not neurology or cardiology. But within GI, he is taking care of the patient referred to him as best he knows how, and that does not mean a minimal approach.
At some point, telling a specialist not to further test and treat a patient is like Ronald Reagan trying to recall a missile that has already been launched by submarine. But I have had patients where I would like to email the specialist and say, politely, Stop!
Johns Hopkins has gotten itself some new hospital buildings, and I am conflicted. It’s a beautiful building, including a new children’s hospital and sparkling, still plastic-wrapped facilities for many, many things. But I’m not sure how often I’ll make my way there.
That’s because internal medicine has no space there (I mean internal medicine as a primary field; cardiology and gastroenterology certainly do). This is not surprising – we are not a money-making subfield. The modern hospital, after all, is built on sexy specialties, not the longitudinal spadework of the primary care provider. When I admit my patients to the hospital, they will be in the “old” buildings, and when I see my patients in the clinic, I will keep seeing them where I do now – in what is admittedly not an “old” building at all, since it was built in the long-ago aughts.
I am also conflicted about the new building’s presence within our East Baltimore community, with which our relationship has not been … uncomplicated. An architect friend of mine, native to and knowledgeable about Baltimore, remarked that my institution presents a closed face to the city with its buildings. There is no streetscape, nothing beyond the blank glass. The main medical campus gets lively only when people get outside, whether it’s to sit in the sun on the grass in front of the monumental Dome or buy something at the farmer’s market. Thinking back to the other medical campus I trained at, NYU/Bellevue, I remember the energy that poured out from the street into the hospital lobby, and how animating it was.
The new hospital building is shut off too. Yes, it is outfitted with restaurants and cafes aplenty, but I don’t know which of our neighbors will eat there or feel comfortable walking in. Maybe that’s an unreasonable thing to expect from a hospital, but I hoped we could do better.