Navigating specialist referrals — when the primary care doctor isn't enough

This article provides guidance about seeking specialist care for older adults. Work with your elder's primary care doctor to get appropriate specialist referrals and ensure good communication between all providers.

Your mother's primary care doctor has done a good job managing her overall health, but her rheumatoid arthritis isn't well controlled. She needs someone who specializes in arthritis. Your father's blood pressure is hard to manage with standard medications and needs a cardiologist's expertise. This is when specialist referrals become necessary.

The role of a specialist is to provide deep expertise in a particular area. A cardiologist knows hearts. A rheumatologist knows autoimmune diseases. A gastroenterologist knows digestive issues. Specialists have training, experience, and often access to tests and treatments that a primary care doctor might not use regularly.

Getting a specialist referral usually requires your elder's primary care doctor to provide one. Some insurance plans require referrals. Some don't. But even if insurance doesn't require it, working through the primary care doctor usually makes sense. They know your elder's history. They can provide context to the specialist. They can coordinate care between specialists.

Asking for a specialist referral is straightforward. Your elder or you can say: I think I need to see a specialist. Can you refer me to a cardiologist, or whoever the appropriate specialist is. Most doctors will do this. If they won't, ask why. Maybe they think the problem can be managed without a specialist. Maybe they want to try something else first. Understanding their reasoning helps.

The wait for a specialist appointment can be long. Getting a referral sometimes takes days. Scheduling the appointment takes more time. The actual appointment might be weeks away. If your elder's condition is urgent, say so. Urgent appointments might be available. But for most chronic conditions, waiting a few weeks is acceptable.

Insurance questions come up with specialists. Is the specialist in-network? Does a referral need to be submitted first? Are there specific specialists that insurance prefers? Your insurance company can answer these questions. Your elder's primary doctor's office usually handles prior authorizations and referral paperwork, but you can follow up to ensure it's being done.

Preparing for a specialist appointment means bringing records. Your elder should bring any recent test results, imaging studies, a list of current medications, and a summary of relevant medical history. If medical records are voluminous, ask the primary care doctor's office to send key documents to the specialist. A specialist doesn't need entire records, but relevant information matters.

Your elder should also prepare a list of questions or concerns to discuss. What's the problem? What are options? What are the downsides of each option? What would the specialist recommend? Writing these down ensures they don't get forgotten in the moment.

At the specialist appointment, good communication is key. The specialist should explain what they're thinking and why. They should discuss treatment options and involve your elder in decisions. They should explain what to expect. If something isn't clear, asking for clarification is important.

After the appointment, the specialist should send a report to your elder's primary care doctor. This report includes findings, recommendations, and next steps. Make sure your primary care doctor actually receives this report. Sometimes reports get lost in the system. If you don't hear that the primary doctor has the report, call and ask.

One challenge with specialists is that they sometimes focus very narrowly on their specialty. A cardiologist might recommend aggressive cardiac medications without considering your elder's overall health picture. A rheumatologist might recommend medications that interact with your elder's other treatments. This is where your primary care doctor is essential. They see the whole picture and can coordinate care, pushing back if a specialist is suggesting something that doesn't fit with the overall plan.

If recommendations from different specialists conflict, this needs to be resolved. Your elder might be caught between a cardiologist recommending one thing and a nephrologist recommending another. The primary care doctor should help sort through this. They might call the specialists directly to discuss. They might suggest a compromise. But the conflict shouldn't be left for your elder to resolve.

Managing multiple specialists requires organization. Your elder should have a medication list updated after each specialist visit. They should know what each specialist recommended and why. They should understand how treatments from different specialists interact. Your primary care doctor's office can help coordinate, but you might need to be an advocate ensuring this happens.

Some specialists want to be the main doctor managing your elder's health. This can be appropriate if your elder's main problem is in that specialty. For example, if your elder has advanced heart disease, maybe the cardiologist becomes the main doctor and the primary care doctor takes a supporting role. But in general, having a primary care doctor coordinating is helpful.

Changing specialists sometimes becomes necessary. Maybe your elder doesn't feel heard. Maybe the specialist's recommendations aren't working. Maybe insurance changes and a different specialist becomes available. If changing becomes necessary, ask your primary doctor for a referral to someone else. Get records transferred to the new specialist.

Communication between you and specialists matters too. If you're supporting your elder and notice side effects from medications a specialist prescribed, tell that specialist. If you notice the specialist's recommended treatment isn't helping, say so. Specialists need this feedback.

The costs of specialist care vary. Some insurance covers specialist visits and tests completely. Some requires copays or coinsurance. Some has higher copays for specialists than primary care. Understanding your coverage helps manage costs.

For older adults with multiple problems, multiple specialists is sometimes necessary. A person with diabetes, heart disease, kidney disease, and arthritis might see an endocrinologist, cardiologist, nephrologist, and rheumatologist. That's a lot of doctors. But each brings expertise your elder needs.

Your role in specialist management is as coordinator and advocate. You help your elder get to appointments. You help them understand what specialists are saying. You help ensure communication between doctors. You watch for side effects or problems. You raise concerns if something doesn't seem right.

Work with your elder's primary care doctor to get appropriate specialist referrals. Ensure your elder understands specialist recommendations. Help coordinate communication between multiple providers. If conflicts arise between specialists' recommendations, ask your primary doctor to help resolve them.