My patient – call her Mrs. Abigail – arrived in clinic on a blustery autumn morning, concerned about swelling in her legs and hands. It came on gradually over several weeks, first in her ankles, then spread up to her thighs and abdomen. Eventually, she noticed that she could not clench her hand into a fist. “I feel like I am blowing up, puffing out like the Michelin Man,” she exclaimed to me. A spirited, anxious woman in her mid-fifties, Mrs. Abigail came to my clinic as so many patients do, seeking an answer and solution.
I ordered several tests for Mrs. Abigail, including urine microscopy to evaluate for protein and an echocardiogram to examine the heart’s function. After a few hundred dollars of testing, we had the diagnosis. Her heart squeezed normally but had some difficulty relaxing and filling with blood, creating a imbalance of fluid in front of and behind the heart. Dubbed “diastolic” heart failure, the condition is a poorly understood cousin of the much more extensively researched “systolic” heart failure. I gave her a pill to help her urinate off the excess fluid and referred her to see a cardiologist.
The cardiologist ordered more advanced testing, including a cardiac MRI and heart catheterization of both the right and left sides of the heart. The extra testing made no difference in the end but added thousands, if not tens of thousands, of dollars to her diagnostic work-up. He gave her the same pill I had to help her urinate off the excess fluid and continues to see her every three months to “co-manage” her heart failure with me.
Over the last decade, the number of referrals has nearly doubled, and now almost ten percent of all outpatient visits result in a referral.  The factors driving this trend are numerous. Consolidation of medical practices has made referrals as easy as a click of a button. In a busy clinic with shorter visits and more medical issues to manage per patient, referrals can be an exercise in saving time and defensive medicine. In an increasingly complex field, referrals can fill gaps in knowledge. And oftentimes, patients themselves expect specialist-level care.
Referrals are exceedingly common but rarely held to scrutiny. Specialists have access to advanced yet expensive diagnostic and therapeutic modalities: bronchoscopy, endoscopic retrograde cholangiopancreatography, heart catheterization, and more. Many times, these are appropriately deployed. However, in many cases, as in Mrs. Abigails’, they are not. Patients who see specialists tend to have higher health spending, even after controlling for health status.
Half of specialists’ appointments are for follow-up care. At least one in six of these could be managed exclusively by a primary care physician, suggesting a role for repatriation of care from specialist to primary care physician.
The United States is a specialist-driven medical system. Sixty-percent of physicians are specialists and only forty-percent are primary care physicians. In other industrialized nations, this ratio is reversed. Medical students are increasingly choosing fields in the subspecialties rather than primary care. However, a primary care-driven health care system has repeatedly been shown to improve quality, reduce costs, and increase equity.
Mrs. Abigail’s story is not novel. It is the norm, and therein lies its insight. In a nation being bankrupt by its medical system, our cost savings are to be found not only in the infrequent outliers but also in the most common practices multiplied over millions of patients. Perhaps my most expensive and lowest-yield order in taking care of Mrs. Abigail was the referral to see a subspecialist for a condition I, as a primary care physician, could manage as effectively, at a fraction of the cost.
Sumit Agarwal is a third-year internal medicine resident physician at the University of Virginia. He is a primary care advocate with an interest in health care disparities. After residency, he will be starting a fellowship in General Internal Medicine at Brigham and Women’s Hospital. You can connect with him on Twitter @SumitAgarwalMD. He was also a winner of the 2016 Costs of Care Story Contest.
 Barnett ML, Song Z, Landon BE. Trends in physician referrals in the United States, 1999–2009. Arch Intern Med. 2012;172:163–70.
 Greenfield S, Nelson EC, Zubkoff M, et al. Variations in resource utilization among medical specialties and systems of care: results from the Medical Outcomes Study. JAMA. 1992;267(12):1624-1630.
 Valderas JM, Starfield B, Forrest CB, Sibbald B, Roland M. Ambulatory care provided by office-based specialists in the United States. Ann Fam Med. 2009;7:104–11.
 Ackerman SL, Gleason N, Monacelli J, Collado D, Wang M, Ho C, Catschegn-Pfab S, Gonzales R. When to repatriate? Clinicians’ perspectives on the transfer of patient management from specialty to primary care. J Gen Intern Med. 2014 Oct;29(10):1355-61.
 Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457-502.