A piece of advice to any specialist who has happened to stumble upon this obscure blog: it's okay just to stick to your organ system and when that evaluation has been completed send the patient back to their primary care provider.
This week a frazzled gastroenterologist called me after unsuccessfully working up a patient's fatigue. I had sent her to this provider because she had symptoms quite consistent with an upper gastrointestinal bleed and and endoscopy was clearly indicated. I really just wanted her to be scoped and sent back to me, but apparently I wasn't clear.
After her EGD and colonoscopy were performed and not all that remarkable, this GI felt obliged for some reason to continue the work up. She started with a chest x-ray and that showed some questionable areas, so she ordered a chest CT which wasn't any more helpful. She added some additional bloodwork in addition to what I had already ordered which wasn't remarkable. By the time she called me she was pulling her hair out in frustration.
This patient did have many avenues to travel down to evaluate her fatigue. Her forty years of smoking had left her lungs tattered and worn. Peripheral vascular disease limited her ability to walk. She had even had one or two small strokes in her 66 years.
All of this information the GI could have seen from the medical record, but there were other reasons not so obvious. She is the primary caregiver for her husband who was severely disabled by a severe stroke two years ago. I care of him too. She takes care of her grandkids, also my patients, who have significant behavioral/school issues. Her kids have had more relapses of meth use than I can count. I see this patient at least a couple of times a week sitting on her porch with her husband smoking a cigarette as I jog by their house that has fallen into severe disrepair. While I believe in evaluating other more medical causes of fatigue, the source of her problems likely has much to do with social issues as any biological one.
I told the gastroenterologist this story which was all new to her and she asked me again if it would be okay if she just sent the patient back to see me at this point. Of course it was okay. I never had any other expectation.