Look, let me say up front that I’m very sympathetic to primary care practices. I mean, truly. My family is lucky enough to have access to a small, intimate primary care practice, and I kid you not, I love those folks.
All that being said, I just had an experience which tells me that changing PCP business models are creating a very, very large problem.
What of my experience? Well, in theory, it was no big deal. I called in after hours to ask about a family medical problem which worried me, and asked for a bit of guidance. I was just concerned enough about a family member’s health to see a bit of extra help.
The response I got was another matter. Rather than asking why I had called after regular practice hours, and what my concerns were, the clinician taking call said (more or less verbatim): “Well, I didn’t see (Jill) yesterday when you brought her in, so I have no idea what’s going on with her. Take her to the ED if you want, but I can’t help you.” I was silent for a bit, shocked by her rudeness (she’s usually very helpful), then said “If that’s what you think” and hung up.
Because I know enough to avoid the ED whenever possible, I held off, and things turned out fine. But this encounter raised a few questions which trouble me deeply:
* Let me get this straight: Are patients supposed to go to the ED first these days so as not to inconvenience their PCP?
* If they do contact an on-call PCP, should they be afraid that their call will be “unsuitable” or not worth addressing?
* Has the whole notion of taking call deteriorated so much that PCPs covering the night shift will only talk to patients they’ve seen recently? If so, they’re nudging many, many patients to the ED who might otherwise just need a word or two.
For many years, the ED was the pressure point in the whole health system, with ED administrators secretly hoping to avoid uninsured GOMER (Get out of My Emergency Room) patients. (Yes, not very sensitive terminology.)
Now, the problem seems DCAHs (Don’t Call After Hours). Greviously-stressed care practices just aren’t prepared to absorb the costs of after-hours care or even telephone advice, and it’s throwing the system out of balance in a new way.
As things stand, the exploding primary care clinician shortage just keeps getting worse and the need for patients to have medical homes is climbing. Pile these issues on top of the already overloaded primary care business — in which margins are so bad that practices are adding day spas, for heaven’s sake — and you’ve got real trouble.
Ultimately, I think all of these problems are going to be resolved, and I’m very clear that PCP practices want to help. In the mean time, someone’s going to have to do a better job of fielding the 5PM to 9AM gap in care. Telemedicine, urgent care centers and retail clinics are making a dent, but they can only make a dent in the problem. This is a very big deal, and it’s only going to get bigger.