Back to Dr. Davidson's Home Page Back to Table of Contents INTRODUCTION As a new century begins, quality, measured in terms of clinical outcomes, cost efficiencies, and optimal utilization of healthcare resources are the hallmarks of medical practice. Primary care physicians (PCP) are the “front-line”—the first access point to healthcare services—and as “gatekeepers,” are charged with ordering and coordinating timely, appropriate diagnostic studies and referral to physician specialists. The primary care physician requires diagnostic competence and effective communication skills. Information transfer between primary care physicians and specialists must be prompt, clear and ongoing to ensure optimal clinical outcomes, resource management and patient satisfaction. Working together, primary care and specialty physicians can concur regarding the indications, diagnoses, and procedures best managed by the specialist and those best managed by the primary care physician. This consensus permits consideration of expediency, cost and clinical outcomes. Quality, cost-effective medical practice is contingent on open communication, collaboration, objective assessment, and diligent follow-up. BEST PRACTICE ALGORITHMS The development of “best practices”—algorithmic pathways for a ear, nose, and throat disorders (ENT)—contained herein involved consideration of clinical outcomes, cost-effectiveness, optimal resource utilization, and patient and practitioner satisfaction. Time management is included in the preparation of these algorithms because of the direct relationship between prompt diagnosis and treatment to clinical outcome, cost-efficiency, patients and practitioner satisfaction. For example, when a procedure such as nasopharyngoscopy can be performed more rapidly by the specialist than the primary care physician, referral is likely indicated and advisable. In the event, however, that the primary care provider or a mid-level practitioner (i.e., nurse practitioner or physician assistant) is proficient to perform a simple procedure (e.g. cerumen removal), evaluation and treatment by the primary care provider may be the best practice. Reiterating the commitment to quality and cost-effectiveness, this set of algorithmic pathways resists the practice of over-prescribing. Newer pharmaceutical agents must demonstrate superior clinical outcomes to justify additional costs. The philosophy communicated in these pathways is explicit and unequivocal— when a less costly agent is available, prescribe it rather than a more expensive drug. For this reason, these pathways include the agents of choice and drug doses for healthy adults. Other patients (e.g., pediatrics, geriatrics, pregnant or lactating women) may require alternative agents and/or adjusted dosages. Finally, in selected instances, the zealous effort to present clear, simple and user-friendly instruction may have resulted in oversimplification. Readers are encouraged to interpret the inclusion of fundamental information as the author’s intent to provide complete instruction, rather than an underestimation of the skills of primary care physicians. This set of algorithmic pathways is not intended to teach diagnosis. For this purpose, readers are referred to the Clinical Manual of Otolaryngology, 3rd edition, by Terence M. Davidson, MD or to the many excellent books of Otolaryngology-Head and Neck Surgery.