Role of a Specialist Versus PCP in Multiple Sclerosis

Peter L. Salgo, MD: We’re having this discussion here with experts, and it’s complicated, and I must tell you listening to this: I understand what you’re saying, and I’m following you, but it’s not trivial. What about the folks out there? The neurologists, the family physicians—I hate to use the word general practitioners because that’s not politically correct here—the people who see all comers. How do you expect them to be educated?

Patricia K. Coyle, MD, FAAN, FANA: What is the slam dunk? The major form of MS [multiple sclerosis] presents with attacks. It’s important to think about MS, to make that diagnosis as early as possible, and to get them on treatment early. And you hope that they do swell. You hope that they don’t transition to secondary-progressive MS and that you can keep them intact by also adding a wellness program and symptom management, etc. That’s what the general practitioner should really be focusing on.

Peter L. Salgo, MD: Can the general practitioner be relied upon to make the initial diagnosis on physician exam, get the right laboratory tests, call up and get preapproval, and get the MRI [magnetic resonance imaging]?

Patricia K. Coyle, MD, FAAN, FANA: Simple question: Do they meet 2017 McDonald (diagnostic) Criteria? If the private practitioner is a deer in a headlight, then no, they shouldn’t be making a diagnosis. If they’re not using those criteria, in my opinion, they shouldn’t be making a diagnosis.

Peter L. Salgo, MD: Right now if you lined up 100 primary care physicians and said McDonald Criteria, would they know what you were talking about?

Patricia K. Coyle, MD, FAAN, FANA: No.

Thomas P. Leist, MD, PhD: No.

Patricia K. Coyle, MD, FAAN, FANA: No, no, they shouldn’t be making the diagnosis.

Peter L. Salgo, MD: The question comes back to, are there educated providers, patients, payers? If not, why not? And can we make that better?

Patricia K. Coyle, MD, FAAN, FANA: I think people have tried to educate them. If somebody goes blind in 1 eye and they have pain in moving the eye, I think most people recognize that’s likely an optic neuritis and that they should get that patient seen, right?

Peter L. Salgo, MD: Right. But this is far more complex I think, right?

Thomas P. Leist, MD, PhD: But it must be constant. Once a patient is diagnosed with multiple sclerosis, this diagnosis sticks for life. So this is 1 of these life-changing diagnoses. From that point of view, a primary care practitioner is probably more somebody who identifies that a patient may be at risk and then requires a neurologist to see this particular patient.

Peter L. Salgo, MD: OK, that’s what I wanted to get at.

Thomas P. Leist, MD, PhD: A neurologist in general, because we will go over many different medications. This sounds a little like oncology when it becomes more complicated—what we do with individual patients—and there are complexities that we are not going to address today.

A general neurologist, a community-living neurologist, will then have perhaps a special interest in MS or somebody who is more electrophysiologically inclined. Again that person says, “I think this is MS,” and may refer to an MS center. Or that person says, “This is a clear case of multiple sclerosis, and I will start treatment at that point in time.” But I don’t think that for a lifelong illness with potential impact of multiple sclerosis, the place of diagnosis is in the primary care physician’s hands.

Patricia K. Coyle, MD, FAAN, FANA: I totally agree.

Maria Lopes, MD, MS: I think we agree as well, especially when you then initiate therapy, because sometimes how we come to know the patient has MS is when they’re placed on disease-modifying therapies. And then at that point we do require that a specialist has been involved and has confirmed the diagnosis in order to approve the therapy.

Peter L. Salgo, MD: I don’t want to cast any aspersions on primary care physicians. To me, that’s an impossible job. Everybody comes through your door, with plantar warts, hangnails, multiple sclerosis. How can you expect these poor folks to be up to date on every specialty’s tests, every specialty’s diagnostic criteria, every specialty’s package to establish the diagnosis? I don’t think that’s possible.

Thomas P. Leist, MD, PhD: But we mentioned a very important part of the role of the primary care physician. Once the patient has been diagnosed with MS, patients are very often overburdened with the diagnosis of MS. And from a neurologist’s point of view, it is very important to have a partner in the general practitioner, primary care practitioner, to take care of the comorbid conditions. Because as we have discussed, this can modify the course of the disease very significantly, to then be a partner in the care of this individual. When a patient is identified as having multiple sclerosis, that patient will have another part of the care team that addresses specifically the MS issues. But the primary care remains very important.

Maria Lopes, MD, MS: I completely agree, there is this aspect of comprehensive care and even a medical home for the patient who has MS because no patient is alike. Some of these patients are young women in the prime of their lives contemplating pregnancy, for example, or they’re pregnant, or they’re post partum. And so the need, if you will, for comprehensive care that brings in multiple disciplines—and that can help the patient and the family in terms of a lifelong disease—is critical, absolutely.

Thomas P. Leist, MD, PhD: It’s referring, not sending away, right?

Peter L. Salgo, MD: I think that’s really important, because if there’s 1 thing we know that primary care physicians are good at, it’s taking care of the whole patient. Perhaps someone is going to help them with a very technical diagnosis, but that patient is coming back to the community, and that patient has got to be managed by somebody. And that patient is probably going to be managed by their primary care physician. It makes sense.