I have made the argument that being the first contact for patients with new symptoms requires skill and experience. That is not something everybody agrees on.
One commenter on my blog expressed the opinion that it is easy to recognize the abnormal or serious and then it is just a matter of making a specialist referral.
That is a terribly inefficient model for health care delivery. It also exposes patients to the risks of delays in treatment, increased cost and inconvenience and the sometimes irreversible and disastrous consequences of knowledge gaps in the frontline provider.
UNNECESSARY SPECIALIST REFERRALS ARE COSTLY
Seeing a high charging, high earning specialist when the primary care provider can’t diagnose and manage the condition involves higher cost and, in many cases, a comprehensiveness that is based on the fact that the patient traveled 200 miles for their appointment. In such cases patents aren’t likely to come back for a two week recheck. Consequently, specialists tend to do more in what may be the only visit they have with a patient.
UNNECESSARY SPECIALIST REFERRALS CREATE TREATMENT DELAYS
For my patients, seeing a neurologist involves a one year wait for the out of state neurologist who does consultations almost 100 miles from my clinic, or a three to four month wait for an appointment more than 200 miles away in Bangor. The situation for rheumatology or dermatology is about the same.
Even if a primary care provider makes a correct referral, patients risk getting sicker and suffering needlessly because of these delays or, for them, nearly insurmountable barriers to travel.
And the days are gone when a rural medical provider could call city specialists several times a month and get free curbside consultations about tricky cases.
Rural America is almost like a different country in terms of the availability of specialist physicians, so less knowledge on the frontlines of medicine is a big deal here. Distance is an overlooked health disparity. I even have patients who hesitate traveling 20 miles to Caribou for an x-ray.
THE DANGER OF NOT KNOWING WHAT YOU DONT KNOW
The biggest concern with the you-can-always-refer mentality is that it actually takes good training and real life experience to know what constitutes an emergency when the clinical signs are subtle and similar to more trivial conditions.
In my own writing I have described the inexplicable phenomenon of clinical instinct and the newbie hubris of the Dunning-Kruger effect and also illustrated many common primary care triage situations:
A rash could be leukemia or idiopathic thrombocytopenic purpura. A sore throat could be glossopharyngeal neuralgia or a retropharyngeal abscess. A blocked ear could be Ramsay-Hunt syndrome, a self-limited serous otitis or sudden sensorineural hearing loss with an abysmal prognosis if not treated immediately with high doses of steroids. A headache or sinus pain could be cancer, and a cough could be a pulmonary embolus or heart failure.
Why are so many people systematically belittling the skills that are needed to be a safe and effective primary care provider? In many other countries, primary care physicians are the backbone of their health care system.
Oh, I almost forgot, our system was never actually designed. It looks the way it does because of market forces, corporate strategies and all those kinds of things.
A Country Doctor Writes: 
I agree, primary health care is ‘a must’ to ensure good(=accessible, personal, continuous, generalistic) health care. This beside the neccesary specialistic health care in Hospitals etc
It is a pity that when you retire you have the most gathered knowlegde and art of profession and intuition to be a better or good or excellent family doctor. I was 30 years a GP in the north of the Netherlands, in the beginning also deliveries and mother and childcare. It is so important to know your patients all this time and this makes that your refarrels improve , while doing this through the years.
I totally agree with your analysis. The response to the writer you refer to, who said it is easy to spot a bad problem and then refer to a specialist, is: IF YOU DON’T LOOK OR ASK, you can’t spot the problem. Students today are not taught to take good histories or do thorough physicals. I just learned this week of another instance, an elderly woman who found a hard, lemon-sized breast lump with an inverted nipple after months of being seen by her PCP
and specialists, who were focussed on her cardiac condition. No one did a complete physical exam!
The big question is, how do we get the attention of those who could remedy American medical education?
Nice work. All true
Hello Dr. Duevefelt – My experience has been that quite often the patient is expecting a specialist referral even though I might be confident that the issue it is well within my expertise to treat. Having been oversight for PAs and NPs I see often the immediate order for extensive, expensive imaging or referral to specialists without considering the most common reasons. Before the firestorm of responses, I have met and worked with excellent PAs and NPs and would consider them for my own and family care. However with the less clinically competent providing a large percentage of primary care I think patients are now use to referrals. I would think it drives the specialists crazy to deal with all the simple issues as well as it completely clogs the referral system causing the excessive wait.
I am a retired Family Doctor who has followed your posts for years. I am similarly perplexed by people and a health-care system that belittles and undermines primary care. Picking out the “wheat from the chaff” is actually a challenging skill and mastered well by many generalist doctors. But there is so much more to primary care than finding and treating the rare, but important ailments. Doctors who relate to the patient and are part of the community have a deeper understanding of the nature of the person who is experiencing symptoms. I submit that his or her management of the given disease is consequently more likely to be beneficial. Primary care doctors also help people change adverse behaviors and seek their optimal positions in life. I have written a biography Windblown; The Remarkable Life of Richard S. Buker Jr., MD; A Family Doctor. The book and a series of my blogs provide more support for our claims of the value of primary care practitioners. My posts and the book can be accessed on my website larryhalversonmd.com.
Corporate medicine goes where the money is and that is specialty care. They hire NPs or PAs for the initial consult then rack up all the ancillary services (labs, x-ray, ECG) then send the patient on. It has been shown that the cost of care rises exponentially with this type of service rather than have a primary care physician see the patient no matter how good the NP or PA may be. Most time the ancillary services are cut in half and the physician may actually be able to provide the care the patient needs at that time. My consultants know when I send a referral I have already done all the easy things so they can do what they were trained to do rather than diagnose the problem.
I COMPLETELY agree – in a capitalist economy market FORCES design systems (including Medicine – under which a huge chunk is Primary Care).