'You don’t need to see an endocrinologist!'

A 35-year-old man called and asked if he could see an endocrinologist. He was recently diagnosed with type 2 diabetes by his primary care physician but questioned the diagnosis. The patient’s mother died from complications of type 1 diabetes. He was concerned that he too might have type 1 diabetes.

We replied that we would be happy to see him but requested that he ask his primary care physician to send him to us as a consult. A short time later the patient called us back. His physician told him: “You don’t need to see an endocrinologist!” He was started on metformin and told that he definitely had type 2 diabetes. The physician absolutely refused to request a consult.

Therefore, we saw him as a self-referral. The patient was slender and physically active. He did not have clinical evidence of insulin resistance. We agreed with the patient that this did not appear to be type 2 diabetes. C-peptide was detectable but low. Beta-cell antibodies were ordered and we initiated insulin.

We subsequently received a phone call from the primary care physician. He was angry that we saw the patient without his permission. He refused to send copies of the patient’s records.

Having worked as a general internist for several years, I understand how challenging it is to practice primary care medicine. Some days are filled with endless requests for prior authorization, fighting insurance companies and completing disability or other forms. The primary care physician always seems to be the one who ends up doing the work no one else wants to do. Too often the primary care physicians get little respect, appreciation and reimbursement for their efforts.

Now that I am a subspecialist, I try to be the type of consultant that I chose to send my patients to. I strive to do right by the patient while supporting the work of my colleagues. However, sometimes I am forced to choose between one or the other. If I must choose, I advocate for the patient whether or not the other physicians agree.

His physician told us he would never send us another patient. This is a difficult situation. I worry about his other patients who could benefit from our expertise but who will not get the opportunity to see us. Nevertheless, if a patient wishes a second opinion, it is their right, whether their physician agrees or not.

Many primary care physicians do an excellent job managing diabetes and other common endocrine problems. However, no one knows everything. If someone asks for a second opinion, I encourage it. It may be hard to swallow our pride; however, we should not forget why we went into medicine. It must be for our patients and not for our egos or bank accounts. At best, a second opinion will support your recommendations; at worst, it will offer another point of view. Either way, the patient benefits by having more information and additional options to discuss and choose from.