2000-06 Diving Medicine and Managed Care

By Fred Bove, M.D., Ph.D.

A diver recently sent me an e-mail about an odd symptom that he experienced after diving. He is an experienced diver who noted vertigo, hearing loss, nausea and vomiting after a dive. The symptoms lasted about two hours and disappeared. Similar symptoms occurred the next day after diving, so he stayed out of the water for the remainder of his vacation, and returned home with no symptoms. On a subsequent dive trip, the symptoms reoccurred. This time he visited his primary care physician and suggested that the symptoms might be related to ear problems. The physician informed him that this was not a diving related problem, no further evaluation was needed, and he prescribed antibiotics. The same symptoms occurred again after diving, so he e-mailed me to find out what to do next.

Most physicians would consider one of the causes of these symptoms to be diving. A diving related disorder must be considered if the symptoms always occur after diving and no other time. Unfortunately, some physicians are not familiar with diving medicine and would not consider a diving related disorder even with the obvious relationship. Even though our correspondent informed the physician about ear problems with diving, he chose to ignore it... or did he?

The primary care physician often works in a managed care insurance plan where he or she receives a fixed amount per month for each patient in the practice. Under this system, referral to a specialist for a more detailed evaluation reduces the physician's income, and a liberal policy of referrals could actually bankrupt the physician and the practice. So, a primary care physician might avoid a referral for this diver by treating what he thought was an ear infection with an antibiotic, thus avoiding a referral fee that the physician would have to pay from his practice allocation.

This incentive for a primary care physician to avoid referrals to specialists has been condemned by many health care and political organizations. Legislation in the Patient's Bill of Rights is intended to prevent this kind of behavior. The incentive to limit care is new, and has been motivated by the spread of managed care.

What should be done for this diver with vertigo, nausea and vomiting after diving? First of all, a diagnosis must be established. The diver should be referred to an Ear, Nose and Throat (ENT) specialist for evaluation of hearing and balance function. The symptoms are suggestive of inner ear barotrauma, and with special testing and examination, this diagnosis can be confirmed or ruled out. Middle ear problems, including infection, a phenomenon called alternobaric vertigo and certain kinds of tumors can sometimes cause these symptoms. In any case, if the physician you are consulting does not understand diving medicine, and is not willing to listen to your history of diving exposure, you need to ask for a consultation with someone who does.

Before you develop an illness of any kind, it is important to read the details of your health insurance policy to understand what is covered. In the case of the diver with vertigo, an ENT visit might require direct out-of-pocket payment. It is also important to understand what type of health plan you are in. If it's a true HMO, you are required to report to your primary care physician for all complaints except emergencies. You should ask your primary physician if he or she is limited in the use of specialists, and if you feel a specialist evaluation is needed you should ask for the referral. Most physicians will not deny your direct request.

We recently created a specialty board in Diving and Hyperbaric Medicine.
You might also suggest to your physician that he or she attend a short course in diving medicine. There are many, all of which provide continuing education credits. You can find information about most of the common disorders related to diving at www.
scubamed.com. This site also has details on our annual diving medicine course as well as our textbook, Diving Medicine (A.A. Bove editor, W.B. Saunders publishers).

Fred Bove, M.D., Ph.D., practices Cardiology, Internal Medicine and Diving Medicine.