by Ken Murray
If you think it’s hard to get an appointment with a family doctor now, just wait until you’re a little older. By 2025, it’d really be best if you avoided getting sick altogether. That’s when America will have a shortage of about 40,000 primary care physicians, according to the U.S. Department of Health and Human Services. Money is at the root of the problem (specialists earn a lot more than primary care doctors), and there is no cure in sight. Many of us won’t be able to get an appointment. At all.
So what’s a patient to do? You may not like the answer, but at least it’s simple: become your own doctor. I don’t mean you should go to medical school, of course. Nor do I mean you should panic-Google your itchy tongue (more on that later). But you do need to take on a new set of tasks.
Let’s look at the three things adult primary care doctors—also known as GPs (general practitioners), or general internists—do best. The first is to offer “episodic care,” meaning the sort of medical attention you get when you come down with something and head over to the doctor’s office. The second is to offer preventive care, helping you to head things off before they become a big problem. And the third is to monitor and treat continuing problems like diabetes or high blood pressure.
These are all essential services, and we’ll miss them when they’re gone. But here’s the best way to keep them—sort of—going.
First, when you get sick, use a walk-in clinic. These are usually called “urgent care centers,” and they’re often open 16 hours a day, perhaps located in a mall or pharmacy. So if your stomach is hurting like crazy, go consult your yellow pages or Google “urgent care” services in your city. In fact, do it before you eat that suspicious-looking soufflé and get too compromised to make good decisions. Check out the walk-in clinics nearby, write down the info, and put it on your refrigerator, so you have it ready. Here’s what you should not do: go to an emergency room with anything other than a true emergency, like a life-threatening problem. Misusing the ER is an incredible waste of time and money.
Second, start taking the lead in your own preventive care. The good news is that the resources are out there, and this wasn’t the case even as recently as five years ago. The best place to go is the website of the US Preventive Services Task Force. This is an entity that was created precisely to allow patients (and physicians) to have the most up-to-date and scientifically supported information on prevention. The recommendations come from non-governmental, non-biased experts, and there are strict rules in place intended to prevent personal biases—and especially monetary biases—from influencing the advice that’s offered.
If your research into preventive care reveals that you’re in need of some screening service, you can refer yourself directly to a facility that will take care of what you need. For example, go to a radiology center for a mammogram, go to a gastroenterologist for a colonoscopy, or go to a cardiologist for a treadmill. Then hit the urgent care center for blood tests, x-rays, immunizations, or other referrals. Keep a copy of all tests in your personal health record (for more information on this point, see my article on preventing medical miscommunications).
Third, if you’ve got chronic problems that require regular attention, start going to specialists for them. Studies show that primary care doctors do neither better nor worse than specialists when it comes to management of long-term problems such as diabetes, so it’s reasonable for you to seek long-term care with specialists, who will still be plentiful, rather than primary care doctors, who may be as rare as giant pandas.
In sum, being your own primary care provider, while not necessarily the most desirable burden to take on, can be a manageable task if you do a little planning and know where to go.
Now, a lot of these suggestions rely heavily on Internet use. That’s perfectly fine. But what’s not fine is frantically Googling your symptoms and coming up with half-cocked diagnoses. Before you know it, you’ll be suffering from smallpox, typhoid, and rabies. Instead, recognize that the worst-case scenario (my sore throat could be cancer!) is not even remotely likely, and stick to sites that offer reputable information. The websites of the American Academy of Family Physicians and the American College of Physicians are excellent and open to the public. Catch a free ride with them.
Meanwhile, current primary care providers can do a lot to help adjust to the new shortage. Every primary care physician should have a website, even if it just has updates on epidemics, downloadable forms, and basic information about the practice. This would save a lot of time in the office. Also, primary care doctors should eliminate hospital care from their regular work. Traditionally, doctors pay bedside visits to any patients of theirs who are hospitalized, in order to provide continuity in the patient’s care. But the emergence of hospital generalists called “hospitalists”—along with more enhanced communication systems—has largely replaced this need. While it’s nice for the patient in the hospital, it’s a huge and inefficient drain on a doctor’s time.
Primary care providers should also partner with urgent care centers and send all their same-day, sick patients there. This way, they stay on schedule, and their sick patients are seen right away, when it’s most convenient for the sick person.
Docs who do these things will have more patients, better informed patients, and restful nights.
Certainly, the shortage of family doctors is going to be a problem, but it also creates opportunities for both patients and physicians to improve existing healthcare outcomes, provided we take the initiative. As for finding a substitute for the deeper sense of reassurance that comes from spending real time with another human being devoted to your health—well, that we haven’t yet figured out.
Ken Murray, MD is Clinical Assistant Professor of Family Medicine at USC.
*Photo courtesy of daveparker.
I’ve already started to see the transition. For several years, our primary care physician’s office has been referring us to the medical group’s urgent care center for eposidic care. It’s worked well for us as patients.
One of the things that makes this transition easier is the computerization of medical records. The urgent care physician assistant has access to all the same information as my primary care physician. And my primary care doc will have all the notes made by the PA.
Sorry, I disaggree on two points. First, I go to GP once every few years, someone listen to my health problems. The treatment is really secondary. Now you are suggesting I talk to myself. It does not have the same placebo effect. Second, More I think we need to redesign our health system, incorporating nurse practitioners, alternative health professionals etc. This can be of course only accomplished by taking both health dispensing power and money from medical profession
I haven’t been to the doctor since the mid 90s. The last time I went I was given a prescription of antibiotics as a placebo for a condition that was almost certainly viral–the doctor said so. I never filled the scrip and have never looked back.
As I hurtle towards 60 I realize I will need some medical care at some point and perhaps the fact that I have no medical records will complicate things, but I am convinced that the balance will go my way by a huge margin. It’s not just the savings, the time and money I will not have wasted. For there is a strong positive benefit to self reliance. My health has gotten more robust. I have had so few health problems since I stopped going to the doctor that I suspect I will probably outlive all my contemporaries who run to the doctor with every petty complaint, but if I don’t, that’s OK too. Quality trumps quantity.
Just as no one, as the newsreel of their life flashes before their eyes, wishes they had spent more time at the office, no one wishes they had spent more time in waiting rooms and hospital beds.
Even though I speak in no professional capacity, seven years of frequent exposure to doctors and hospitals (with a severe chronically ill patient) have led me to believe things could be done better. Much of the country’s long term debt load is affected by the number of times that the chronically ill patient feels compelled to go to the hospital, when a long night at home seems too risky. I believe that circumstances such as this could be greatly alleviated if doctors were able to set up alternative local systems run by volunteers. This is especially important now, as access to transportation is not readily available for lower income, when often the hospital they need to be admitted to is hours away.
Thanks for all your comments!
Stan, I’m coming from a position of looking at what alternative might exist, if you CANNOT get into a GP, because there is such a shortage as predicted. You may need to get your placebo effect from another type of provider.
Becky, fascinating innovative concept.
Urban, I hope you service your car more often than yourself! While I think we do go overboard, doing needless and unproven things like an annual physical, a periodic health assessment is probably worthwhile to pick up problems that are fixable, when they are early. When the axle breaks because of the chronically mismatched air pressure, it is too late. 60 is a good time to check in.
Jenson, thanks for the observations.
What about those of us who do not live in cities? There are no urgent care clinics within an hour of the small towns in our region. Only a small community hospital. There are only four cities in our entire state. The largest town in our region has only 6,000 people.
Rebecca, I despair for the rural environment. This has been a problem for as long as I’ve been in medicine (>30 years). If anything, it is getting progressively worse for a number of intertwined reasons.
One promising approach on the horizon is what’s called “Telemedicine”, which involves interacting with a clinician over a teleconference. Obviously no physical contact takes place, although using a nurse at the patient end can deal with some of that.
http://www.telemedicine.com/whatis.html
Reno/Sparks, NV is starting something new with Renown Healthcare. Our doctor will only be seeing 400-600 patients and in addition to your regular insurance you will pay $55 per patient per month. This entitles you to be seen within 24 hours and to have your phone call returned within 24 hours. He is moving to the south part of Reno and we live in Sparks (north). I will pay the price because he is an excellent physician. After checking the other names suggested out (would not have to pay for them) one will be in our area once a week and is a sports med and another is older and does not come to our area. Lake Tahoe has arrangements that are much more expensive to stay with one physician, like $800-$1000 per month. Medicine is changing and we all have to be flexible and do what is best for us and within our budgets.
In my area we only have the ER and the Dr.’s office.If we go to the ER we have to call and get authorization first or the insurance won’t cover the bill. In my area I once took my husband to the ER for a allergic reaction to something. Four hours later and many unneeded tests later found he was allergic to nuts and soy. Dr. told him to go home and take Benedril. It cost $400.00 for the ER visit not counting tests. Next time I will think twice about doing that if it isn’t a life threatening condition.
I’m not sure how you can write this without at least mentioning how the American Medical Association bears sole responsibility for this “crisis.”
Despite clear demographic evidence, the AMA has been insisting that we were going to be experiencing a physician “glut,” and convinced Congress to limit the number of residencies Medicare funds at 100,000 in 1997. That cap remains today. And a new medical school has not been opened since the 1980′s. The AMA holds great sway over how physicians are reimbursed, and could make changes to make primary care more competitive. But they choose not to. Why? Why restrict the training of new doctors when we don’t have enough doctors and the problem will only get worse? Only the AMA seems unaware of this problem.
People will literally suffer and die because there are not enough primary care physicians. But the AMA–which has the power to fix the problem by allowing more residencies, opening more medical schools, fixing problems with reimbursment–refuses to do so. That is absolutely wrong. Immoral, unethical, wrong. Any piece about the physician shortage should start with how the AMA could fix the problem but refuses to do so.
More: http://www.forbes.com/2009/08/25/american-medical-association-opinions-columnists-shikha-dalmia.html
Primary care is a must. I will not see a specialist without consulting mine. I want my PC physician to recieve all information , these are the people who need to know all information. I must say I’m spoiled the group I go to has walk in hours 7-12 six days a week for one issue illness. Primary care is the back bone of health care..
Doctors have varying reactions to patients who do their own research. When visiting a new doctor (e.g., at an urgent care clinic), I have to toot my own horn extensively before doctors will accept my input. And if I’m feeling sick, I’m in no mood to list my first author papers in highly ranked medical journals, which are irrelevant anyhow because any educated person can read reports from the Institute of Medicine (IOM) and the Centers for Disease Control (CDC). When I go to the doctor, I expect to be treated as an equal because professionally I am an equal partner, and so far I’ve encountered condescension as often as not.
Great to encourage more folks to know and behave in ways that gives them some control and planning over care. As a family doctor who is phasing out of practice at 67, I realize that my replacements are different in many ways from my cohort, but that is as it should. However, along with the lack of family doctors, the grim statistic that family doctors are not accepting new Medicare patients at an alarming rate. Whatever the rationale for this – and those who refuse my generation have many rationales, most of them economic – the moral position of primary care clinicians is eroded and the trust of the public, which is shaky to begin with, suffers even more.
These are very good suggestions at first glance. But if you think about them a little deeper, enormous flaws come up. You are assuming that the patient is rational and intelligent. Many are. However, most people who choose to forego PCPs are unlikely to have the intelligence and organizational ability to keep this all in line. Even relatively smart people can’t decipher a radiology report, not to mention the fact that an insurance payor is more likely to reject payment on a diagnostic exam that lacks a referral. There is also very little control on how many exposures patients can have to radiation when they can bounce from facility to facility getting X-rays and CT scans whenever they feel necessary. It’s very easy to see these things working when you are someone who has spent time in the profession and knows how everything works. Probably less than 5% of the general population has any clue how work flows from provider to provider. Assigning all in-patient services to a hospitalist assumes that all people with similar training have the same abilities, which is unfortunately untrue. Also, it would require impeccable, portable, secure records. Again, these are very interesting and innovative ideas, but ultimately will cause more problems than they solve. Efficient primary care can be delivered by providers who embrace technology (telemedicine, etc.), who make themselves available at different hours (nights, weekends – to avoid ER trips), and who work to achieve health, not just do the minimum to avoid a lawsuit. Ultimately, the liability and compensation systems that are set up now are ineffective in achieving these goals.
I loved your article on how doctors die as it describes my sentiments exactly, but this article on how patients can make up for the lack of primary care seems off base. I think current FP’s can do well by planning in their schedule for acute visits and they can partner up with physician extenders in their own office to see overflow acute patients. The wise use of physician extenders can improve the salary of an FP as well as provide excellent primary care. I believe Primary Care residency training programs should train Nurse Practitioners side by side with residents to the benefit of all and the Federal Govt should make it easy for docs to hire them.. All would win out.
Dr. Murray, have you read ‘Where there is no Doctor’ ? An excellent read.