DEAR DR. ROACH: Would you please explain the medical purpose of a primary care doctor? My expensive insurance permits me to go wherever and to whomever I wish. However, I am told invariably that the doctor I wish to see will not see me unless my primary doctor refers me. Do those physicians get a cut every time you go to another doctor? It seems that every time I go to my primary, he sends me somewhere else for diagnosis or treatment. I am beginning to believe the PC is useless, and this is a scam. — R.L.M.

ANSWER: Full disclosure: I have been a primary care physician for more than 20 years. I have found that there are different styles among primary care doctors, and different expectations among patients. Overall, a PCP refers a patient to a specialist in about 9 percent of visits, a marked increase from 1999, when 5 percent of visits resulted in a referral. A “cut” of the specialist’s fee, or a “kickback,” is illegal.

In the best of situations, your primary care doctor knows all your conditions, uses specialists judiciously for complex or difficult diagnoses and coordinates your care. Many, but not all, specialists prefer to deal with just one problem, diagnosis or organ system, and leave it to the PCP to make sure your other conditions are being taken care of. Making sure one specialist’s treatment doesn’t worsen another of your problems is also in the domain of the PCP.

Your PCP may be referring you more often than you’d like due to a misunderstanding of expectations. It may not feel comfortable to bring it up, but honest communication is the key to a successful relationship. It’s OK to say you prefer not to be referred as often, and your PCP should take your concerns seriously.

DEAR DR. ROACH: I have been suffering approximately three years from burning mouth syndrome. I am female and 73 years young! Seeing four ear, nose and throat specialists, I was prescribed amitriptyline; Nexium, since it was thought that GERD was the culprit; a mouthwash with prednisolone; and another mouthwash, which I rejected, because I frequently use liquid Benadryl to reduce the burning temporarily.

I take Ativan (.5 mg) every morning for anxiety. I live with stress and intermittent depression caused by loneliness; I lost my husband three years ago and have no family. — U.E.

ANSWER: Burning mouth syndrome is characterized, as its name implies, by a burning sensation in the mouth, with no other dental or medical cause identified. It is most common in older women, and often is worse in the evening. Several medical conditions, such as dry mouth and vitamin deficiency, can cause a burning sensation, but in BMS, none of these is present.

There is an association between depression and burning mouth syndrome. You do sound as though you may have some element of depression. Although you are on an antidepressant, amitriptyline, you are probably on the dose for nerve pain (usually 10-50 mg) as opposed to the antidepressant dose (often 300 mg per day or more). Amitriptyline isn’t a great choice for depression for a woman in her 70s due to side effects at that high a dose (including dry mouth!).

I would consider a different medication, such as venlafaxine or duloxetine. These can reduce pain directly as well as treat your depression. An internist or neurologist may be able to provide expertise complementary to your ENT doctors’.

READERS: The booklet on COPD explains both emphysema and chronic bronchitis, the two elements of COPD, in detail. Readers can obtain a copy by writing: Dr. Roach — No. 601, Box 536475, Orlando, FL 32853-6475. Enclose a check or money order (no cash) for $4.75 U.S./$6 Can. with the recipient’s printed name and address. Please allow 4-6 weeks for delivery.

Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or request an order form of available health newsletters at P.O. Box 536475, Orlando, FL 32853-6475. Health newsletters may be ordered from www.rbmamall.com.

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