When an Apple a Day Isn't Enough

If you have signs or symptoms that seem to defy explanation or have resulted in conflicting opinions from different doctors, you may want to see a specialist. Ditto if you have an unusual condition or one that has caused complications and doesn’t get better despite treatment with your primary care physician.

Most patients are referred to the appropriate specialist by their primary care physician, particularly in cases such as cancer or other serious conditions beyond the purview of most primary care doctors. But some people may seek one on their own if they feel they’re not getting the help they need from a regular physician or if they read or hear about particular procedures that only a specialist can perform.

If you think seeing a specialist would be beneficial for you, ask your primary care physician for his or her opinion and perhaps a referral. Good doctors like to work with good doctors, and he or she probably knows of an appropriate specialist with a strong reputation. If you are considering making an appointment without a referral, check with your health insurance carrier to make sure the visit will be covered.

Below is a sampling of the symptoms of some common maladies, and the types of specialists who may be able to help.

Case Study #1
For a month each spring, you have a runny nose, swollen and watery eyes, sneezing, coughing when you lie down at night, and fatigue. Over-the-counter antihistamines and decongestants just aren’t enough to soothe the symptoms of hay fever and get you  through the day.

Stopping the Sneezing
Many people simply tolerate their allergies because their symptoms are mild or they don’t know help is available. Others, who have a more severe condition or one that interferes significantly with their lifestyle, seek care with an allergy or asthma specialist. “People have different tolerances,” says Harold Kaiser, MD, an allergist and the founder of Allergy & Asthma Specialists in Minneapolis. “Is it a nuisance, or is it a disability?”

Allergists evaluate signs and symptoms in everyone from infants to adults by conducting skin and breathing tests, X-rays, nasal smears, and blood tests. Then they discuss options for therapy, such as medication or allergy shots. Typical complaints range from hay fever, asthma, sinusitis, drug allergies, insect hypersensitivity, anaphylaxis, skin problems, and food allergies to immunodeficiency and lung diseases.

Allergy and asthma specialists must complete a residency in internal medicine or pediatrics followed by a two-year fellowship in allergy and clinical immunology. They are certified by the American Board of Allergy and Immunology.

Kaiser says about half his patients are referred by primary care physicians or ear, nose, and throat specialists; the other half are self-referred or referred by friends. “(Patients) can always ask their primary care physician, ‘Should I see a specialist?’” he says.

Case Study #2
You’re out walking the dog or mowing the lawn when you notice tightness in your chest and a shortness of breath. When you stop to rest, the pain goes away, but then it comes back again the next time you’re physically active.

Taking Care of Your Heart
If you have unexplained chest pain—even if you have an electrocardiogram and it’s normal—you should see a cardiologist, says Kenneth Baran, MD, cardiac catheterization and medical laboratory director at United Hospital’s John Nasseff Heart Hospital. “That’s the time people should see their doctor and get it evaluated,” he says. Exertional angina, or chest pain while physically active, is one of the most common reasons people seek out cardiologists like Baran.

Cardiologists treat problems involving the heart, arteries, and veins. They perform diagnostic tests such as magnetic resonance imaging (MRI) and fast-computed tomography (CT). Cardiologists also formulate treatment plans and offer follow-up care. They are proficient in diagnosing and treating problems such as coronary artery disease, arrhythmias, hypertension, cardiomyopathy, chronic congestive heart failure, and heart attack.

Baran, who is an interventional cardiologist, also does some specialized procedures that involve stretching a narrowed mitral valve or closing a hole between the upper chambers of the heart. It isn’t unusual, he says, for people needing those procedures to call him directly, but most of his referrals come from other cardiologists or primary care physicians.

Cardiologists must complete a three-year residency in internal medicine, undergo three years of specialized training in their field, and pass the American Board of Internal Medicine cardiology examination. They may subspecialize in four fields: interventional cardiology (perform procedures such as catheterization and stent insertion), electrophysiology (treat the electrical system of the heart), nuclear cardiology (evaluate pump function, blockages in coronary arteries, and damage to the heart), or echocardiography (perform echocardiography and transesophageal echocardiography).

Case Study #3
You’ve suffered through years of heartburn that gets worse when you lie down at night, difficulty swallowing, reflux of food or liquids, coughing, wheezing, asthma, hoarseness, and a sore throat.

Soothing the Burn
These symptoms are typical of gastroesophageal reflux disease (GERD), a common condition that can lead to narrowing of the esophagus or a precancerous condition called Barrett’s esophagus. “If someone has had that year after year, that might be an indication that they should be referred,” says Paul Yakshe, MD, president of Platinum Health, his private practice in Maple Grove. Yakshe also performs procedures at Fairview Medical Center and other area hospitals.

Gastroenterologists have a particular interest in diseases of the digestive tract (esophagus, stomach, pancreas, biliary tract, small intestine, large intestine, and liver). They treat conditions that are relatively rare and aren’t typically seen by primary care physicians, Yakshe says. In addition to evaluating symptoms, gastroenterologists also conduct screening and diagnostic tests like colonoscopies and upper endoscopies.

Most all patients are referred to Yakshe by a primary care physician for evaluation of blood in stool or vomit, a major change in bowel movements, unexplained weight loss, recurrent abdominal pain, frequent nausea or vomiting after eating, or abnormal test results. Yakshe commonly treats conditions such as long-term GERD, peptic ulcer disease, hepatitis, inflammatory bowel disease, irritable bowel syndrome, gallstones, or pancreatitis.

Gastroenterologists must complete a three-year residency in internal medicine before doing a two- to three-year fellowship in gastroenterology and pass a gastroenterology examination administered by the American Board of Internal Medicine.

Case Study #4
Sharp pains pierce one side of your head, you’re nauseated and you can’t stand light or sound. You call in sick to work—again—and resign yourself to spending the day in bed.

Stopping the Throbbing
Frederick Langendorf, MD, a staff physician in the Neurology Department at Hennepin County Medical Center, in Minneapolis, says a specialist can help with persistent neurological problems like migraines. “If something isn’t going right—for example if someone has epilepsy and they take their medications and their seizures don’t go away—they should ask their primary care physician if they should see a neurologist,” he says.

A neurologist assesses and treats nervous system disorders, such as those of the brain, spinal cord, nerves, and muscles. Neurologists conduct diagnostic tests, including magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), spinal tap, electroencephalography, computed axial tomography (CAT), electromyography (EMG), and blood and urine tests. They then make treatment recommendations that may involve medication, surgery, or other therapies.

Most of Langendorf’s patients are referred by a primary care physician, but some—especially those with a family history of a particular neurological disorder—may refer themselves, he says. Some common examples of conditions treated by neurologists are persistent pain such as migraines, stroke, numbness, visual complaints, epilepsy, cognitive complaints including Alzheimer’s disease, and movement disorders such as Parkinson’s disease. They also see patients with neurologic complications of other conditions.

Neurologists must complete an internal medicine internship followed by a three-year neurology residency before they are certified by the American Board of Psychiatry and Neurology.

Case Study #5
You notice a lump in your left breast during your monthly self-examination. Alarmed, you call your primary care physician, who confirms your suspicions and refers you to an oncologist/hematologist. 

Treating the Disease
Anyone who has recently been diagnosed with cancer will likely be referred to an oncologist or surgeon shortly after his or her diagnosis. Thomas Flynn, MD, a medical oncologist and president of MN Oncology/Hematology in St. Paul, commonly evaluates and treats patients with leukemia, lymphoma, and breast, colon, prostate, or lung cancers. Most are referred to him by a primary care physician or a surgeon. “If somebody does have a diagnosis of cancer, they should ask their doctor if they should see an oncologist, if that hasn’t already been recommended,” says Flynn.

An oncologist/hematologist assesses the patient’s condition, orders any necessary tests, recommends a course of therapy (which may include radiation, surgery, chemotherapy or a combination of these), and then provides follow-up evaluation and treatment. He or she can also further specialize in radiation oncology, which involves treating tumors with radiation; obstetrical/gynecological cancers such as ovarian, uterine, and cervical cancers; medical oncology, or what Flynn describes as the “quarterback” of cancer treatment; pediatric oncology, which involves treating cancers in children; and surgical oncology, which includes biopsy, tumor staging, and surgical removal of malignancies.

After a three-year residency in internal medicine or pediatrics, oncologists then must complete a three-year fellowship in oncology/hematology and pass an examination administered by the American Board of Internal Medicine.

Case Study #6
The joints of your fingers hurt and often feel stiff or numb. It’s hard to open jars, and your hands are beginning to look gnarled. You deal with pain on a daily basis.

Minimizing the Ache
Chronic pain is one of the top reasons patients seek out Jesse Ploessl, a chiropractor in private practice in Plymouth. “Most of the patients I see have tried everything else,” he says. “They’ve gone the traditional route of physical therapy and cortisone injections. They may be looking for something else before they turn to surgery.”

Ploessl, who is a chiropractor rather than a physician with a specialty in pain medicine or management, performs stretching and chiropractic adjustments and counsels patients about nutrition and exercise. He treats people who are suffering from both chronic pain, like arthritis, and from specific injuries or traumas. “The more things you can do in the recovery process, the faster people are going to heal,” he says.

One of things that most accelerates recovery, Ploessl has found, is the BioFlex laser from Meditech, which can cut the time it takes to rebound from sports injuries and surgery in half. It also can be used to treat chronic pain and musculoskeletal problems. The laser is a “cold,” or “lower-level” laser that doesn’t damage the tissue; rather, it helps the body stimulate the healing process. “We’re really seeing some good results,” he says. “It’s another tool that I’m able to use to help a wider range of patients.”

Chiropractors treat arthritis, sciatica, and tendonitis; rehabilitation from sports injuries or surgery; and conditions such as diabetic neuropathy. They must attend four years of chiropractic school after they receive their bachelor’s degree. Physicians who are specialists in pain medicine or management are certified by the American Boards of Anesthesiology, Psychiatry & Neurology, and Physical Medicine & Rehabilitation.

Insurance and the Specialist: Know Before You Go If you don’t want to be faced with an unexpected bill after your visit to a specialist, you need to untangle all insurance issues before you make an appointment. The first step is to find out if you need a referral, says Roger Feldman, Blue Cross professor of health insurance at the University of Minnesota. Some health maintenance plans (HMOs) require a referral, especially if you plan to go outside the predetermined primary-care system. “The ‘gatekeeper plan’ focuses very often on a primary-care clinic, which serves as your gatekeeper,” Feldman says. Next, determine your health plan’s copayment for seeing a specialist. Preferred provider organizations (PPOs), which are similar to point-of-service (POS) plans, have a preferred network of doctors or hospitals that have contracted with the plan to provide services at a discounted rate. “As long as you go to a specialist that is within the network, your copayment or cost-sharing component is lower,” Feldman says. If you go outside the network, you’ll typically pay a higher copayment as well as a percentage of the cost-sharing component of the service. As an example, Feldman says to consider a hypothetical visit to an ophthalmologist that costs $400. A typical copayment inside the plan may be about $15 compared to about $141 in cost-sharing if you go outside the network. In addition, Feldman cautions, some plans offer no coverage at all for visits to specialists outside the network, particularly in areas such as chiropractic care and mental-health and chemical dependency services. The best strategy is to stick with specialists within your plan’s network, Feldman says, “because network specialists have agreed to accept the plan’s usual and customary payment as the full payment,” he says. If you go outside the network, you may have to pay for costs above the customary payment. If you want to visit a specialist outside the network, be sure to call both the specialist and your health plan first. “If you’re going to go to an out-of-network specialist, it’s very important to ascertain what the cost of that is going to be,” Feldman says.