This expanded role of the primary care physician not only requires enhanced diagnostic competence but also effective communication skills. Ideally, information transfer between primary care physicians and specialists must be prompt, clear and ongoing to ensure optimal clinical outcomes, resource management and patient satisfaction.

While it is beyond the scope of this discussion of clinical pathways to consider techniques and strategies to initiate and maintain productive communication between primary care and specialty physicians, the importance of these exchanges can not be underestimated. The strength of the relationship between primary care physicians and specialists is often a key determinant of the referral process and resulting clinical outcomes. Supported by knowledgeable, attentive specialists, primary care physicians may confidently manage a wide range of acute and chronic conditions.

Working together, primary care and specialty physicians can concur about 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) -- considered clinical outcomes, cost-effectiveness optimal resource utilization, patient and practitioner satisfaction. These best practice algorithms must be prefaced by the acknowledgment that overall interest, training and experience especially diagnostic ability, does and should continue to dictate individual physician referral patterns.

Naturally occurring variations in practice patterns and individual preferences result in some physicians who view uncomplicated procedures as within their domains and others who habitually refer complex procedures to specialists. These variations are often attributable to availability of and access to specialists. Classically, rural primary care physicians perform more procedures than their urban counterparts.

Time management concerns were examined closely during preparation of the algorithms because of the direct relationship between prompt diagnosis and treatment to clinical outcome, cost-efficiency and satisfaction for patients and practitioners.

For example, when a procedure, such as nasopharyngoscopy, can be performed more rapidly by the specialist than the primary care physician, referral is very 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 and available to perform a simple procedure (e.g. cerumen removal), evaluation and treatment by the primary care provider may be the best practice.

Evaluation of allergic rhinitis is one instance when direct referral to the ENT physician has the potential to improve clinical outcomes and patient satisfaction while simultaneously saving time and money. Over the course of a year, the primary care physician may incur monthly or even bimonthly visits from the patient suffering from this condition. Following two or three visits to the ENT physician, many patients with allergic rhinitis can be effectively managed with a single or biannual visit to the primary care physician. This example illustrates referral as the best pathway in terms of quality, patient and practitioner satisfaction and cost.

Reiterating the commitment to quality and cost-effectiveness, this set of algorithmic pathways resists the practice of over-prescribing. Newer pharmaceutical agents must demonstrate clearly 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, obstetrics) 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 some oversimplification. Readers are encouraged to interpret the inclusion of fundamental information as the authorÕs 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, 2nd ed., 1992, McGraw-Hill, New York, by Terence M. Davidson, M.D. or to the many excellent books of Otolaryngology-Head and Neck Surgery.

Acknowledgements

Credit goes to Barbara A. Stribling, secretary to Dr. Davidson for her hard work in typing, illustrator skills and putting together the algorithm materials; and Joanne Anderson, medical illustrator at the Veterans Administration Medical Center, San Diego for finalizing the algorithms.

Thanks also to Dr. PeterFalk, Dr. Quynh Nguyen and all the UCSD ENT and primary care physicians who have reviewed and made contribution.

Special thanks to Albert Merati, M.D., for contributing the Head and Neck Surgery Questions.

Many thanks to the following individuals who participated on the editorial review board:

Ronald J. Gebhart, M.D.
Chief Consultant, Primary and Ambulatory Care
VA Headquarters

James Tuchschmidt, M.D.
Clinical Manager
VISN 20

Jacqueline Parthemore, M.D.
Chief of Staff
VAMC San Diego, CA