I'd just read a recent study in the Annals of Family Medicine showing that comprehensive medical care is associated with lower costs and fewer hospitalizations. The study had some limitations, but it reinforced what most doctors and patients intuitively understand: fragmented care is worse for everyone and costs much more. I felt terrible that I was about to contribute to the fragmenting of care for this patient.
But our system is set up to favor fragmentation. It's so much easier to write a referral to a gynecologist than to do a pelvic exam myself. It's far quicker to refer to a rheumatologist than to figure out which complex tests to order, and then have to follow up on the results and figure out what they mean. It's much simpler to refer to a neurologist than to take the time to figure out if a patient's dizziness is serious or not.
In our current environment, being "comprehensive" just means more work for the primary care doctor. No one is allotting more time for this work or reimbursing for these extra efforts, so it's no wonder that most patients leave their doctors' offices with a fistful of referrals.