Primary Care Access, the ED, and 1972

Stimulated by an entry over at Medical Humanities, what started as a comment took up too much space, so it goes here, instead:

There are many who believe with total sincerity that more primary care offices will alleviate the burden on ED’s; this is hamstrung by the horrid pay primary care docs get, so that currently they have to operate like airlines, and overbook. Too many empty seats/open appointments = financial disaster. There isn’t a lot more money coming to primary care in the near future. So, ED = safety valve.

That’s one of the big reasons why a lot of my patients in the ED have insurance and a primary doctor, but they (not unreasonably) believe their pneumonia symptoms shouldn’t have to wait 2 weeks for the next appointment. They come to the ED, they wait, but if willing to wait they’ll get seen. (If minor care clinics would bill insurance, a LOT of those people would flee to them, but the minor care owners have seen what bargaining with the crocodile has done for hospitals and conventional primary care, and want nothing to do with them).

To me, one of the biggest reasons ED volume continues to grow is that office medicine is still practiced like it’s 1972: wait a week or three for your appointment, take this chit to the lab, they’ll draw your blood, come back in a week and we’ll review your tests, then order some more studies if we need them. (And it’s that way for doctors, too: I had a stress test done about 6 months ago (I’m just fine, thanks) but I had to call six times over 10 days to get the result, and that was after waiting the four days they said it’d take to have it read, which was utterly ridiculous). Compare that to the ER: tests drawn and resulted in about 2 hours, decisions made on the tests; subsequent emergency tests readily available, usually around the clock. Americans (and not just Americans) are voting with their feet and choosing the ED, and not because it’s the shiniest place with smiling people, they come because we’re ready to see them around the clock, and we’re capable.

As for the PCP’s: there are about three who get bent out of shape when their patients go to the ED without telling them, and they are very good, old-school docs. They come in and see their patients in the ED, and admit themselves if needed. The rest are resigned to the current system that penalizes the office doc for admitting their patient but pays the hospitalist to admit the same patient they don’t know from Adam.

And, despite how screwed up the system is (and it is), a lot of terrific people work tirelessly to keep it moving, to keep helping patients. Frankly, it’s a wonder it still works at all. But it’s time we had a look at patient expectations about waits (most of which are reasonable concerns) and start moving the system to accommodate those concerns outside the ED. Without breaking the bank.