Hernia UnRepair

Have we missed the mark on PCPs as the Quarterback of care? Here’s one story to put in the “probably yes” column:

So my wife was borderline ecstatic when she found out I didn’t need hernia surgery because I’m like a 3 year old with pain and recovery….My specialist for hernia repair sees about 1,400 patients a year for new hernia consults but ~50% of them or 700 are for hernias that aren’t hernias - the primary care doctors referring are often guessing and they are wrong ~50-60% of the time, Rajnish Tandon, MD told me this week during my consult. He even said some PCPs will also order up CT scans first to try to solve the problem on their own, but sometimes those scans can show a tiny image of a tear hidden in the wall that just doesn’t need surgery.  But because the scan result is “positive” the patient gets the procedure to fix what doesn’t need fixing, and big shocker—their pain returns within a month.  “I don’t need to do a CT – I just know,” he said. This isn’t brash medicine, it’s his mindset, training and decades of experience not unlike a lot of specialists who rely on clinical judgment to diagnose, which is an underappreciated benefit of going to a specialist.  I wonder why so many insurers now cap access to them, requiring a PCP visit and referral, even though by doing so a lot of these patients end up in a cycle of waste and delays, misinformation, confusion, higher cost and if you’re anything like me, an untreated hernia that’s not a hernia after all. My total cost of care – inclusive of a PCP visit, an orthopedic visit, an x-ray that was ultimately normal, 4-5 “turn your head Bryan and cough” situations, could probably have been simplified into just one 15-minute boil the ocean moment. I even had an ultrasound at one point and the tech handed me a printout, which I proudly put on the fridge, next to an old “Tommy Is Student of the Month” certificate kind of like that picture of your first born still in the womb. “What in the world is that?” my wife said. “It’s my hernia. At least I think it is…get back to me in March.”

Of course the good news in all this is I don’t need surgery according to Dr. T, but the bad news is we don’t know what it exactly is and how best to treat it without rest. The problem with muscle strains, tissue strains and anything that’s a not a tear or a break is that fixing it is harder than getting the kids out of bed for Sunday Mass. Rest is not really the prescription I want even if it’s probably the right thing, nor is reliance on Tylenol. As strains go, this one seems chronic. As doctor visits go, mine with Dr. Tandon was worth every penny, even if that’s all I have left in the bank.

The whole 4.5 month experience has left me with 2 thoughts - how in the world do people navigate the health system, and shouldn’t we just move specialists to the front of the line? I have decent access to clinicians my dad knows and I’ve come to know, and even then the system took me down paths and costs I should have avoided. Imagine Joe America? Part of the issue is there aren’t enough primary care doctors to start, a dearth of options in rural America - some of it is the wacky insurance system, but of course a lot of it is just that stuff like pain is hard to pinpoint. I do wonder if primary care doctors will no longer be a thing in 2050. I mean, gen Z doesn’t really care about that, they have their apps and watches, sleep monitoring technology, therapists, and oodles of information telling them how to take care of themselves, where to get a test and how to function. Some companies now help you diagnose and fix your pain at home. I think these are good inventions particularly since we have a shortage of PCPs some working through retirement, but the times are changing. Telehealth and virtual care are helping give specialists a new vehicle to see patients. Why not move specialists who have the training and clinical judgment up to the front, not universally, but for hard to figure out stuff - rashes, anxiety, and yes that strain in the groin that the boys down at the gym and the google on your computer says is a hernia.