05/30/2026
Continuity matters. We see situations like this often. Short visits and fragmented care don’t serve patients well.
A 77-year-old marathon walker started having headaches. She went to her primary care office and saw a nurse practitioner. Then a PA. Then back to the PA. Then an ER. Then the PA again. The PA decided she had anxiety and prescribed fluoxetine. Then she finally got back to her neurologist, who took her history, examined her temporal arteries, and ordered a sed rate. It was 41. She had giant cell arteritis, a vision-threatening diagnosis that had been sitting in front of every clinician she saw for months.
Reeta Achari, MD, a neurologist in solo private practice in Houston for 25 years, is the one who finally caught it.
By the time the patient reached her, she had been through two Medrol dose packs, a course of NSAIDs, a misdiagnosis of anxiety, an ER visit that bounced her back to the same primary care office, and four separate clinicians across the cascade, none of whom was her physician. She had never actually seen her primary care physician. She saw "people in that clinic." The patient herself told Dr. Achari, "if you think I need fluoxetine I'll be on it, but I don't think I'm anxious and this headache is just crazy."
The team-based-care model treats physician time as substitutable. It is not. Holistic differential diagnosis on a multi-system presentation in a 77-year-old requires single-clinician continuity. The cascade above is what non-continuity produces. Giant cell arteritis is not simple. You have to think about it. You have to connect a headache, joint pain, jaw claudication, and an elevated sed rate in a patient who has never had headaches before. You have to put your hand on her temple. None of that happens in a five-stop cascade where every clinician inherits a partial story.
Dr. Achari opted out of Medicare years ago. She now runs a subscription model with a quarterly fee that middle-class patients can afford, with scholarships for the patients she has cared for over decades. She is a fourth-generation physician. She watched her father practice 40 years ago, when not everybody had managed care. She is not nostalgic. She is operational. Her argument is simple: if physician time is the diagnostic instrument, then a workflow that puts the physician at the end of a five-step escalation has broken the instrument.
"No physician touched her."
Listen to the full conversation on The Podcast by KevinMD. Link in the comments.
