"Did you see/Follow up with your Primary Doctor..."

[Roy Fokker, BSN, RN]

Hey y'all

How often do we ask patients when they come into the ER if they've seen their PMD for the issue? How often do we discharge pts. with the instruction to "follow up with your PMD?"

See I was hanging out with some friends at a different watering hole than my usual spot. Got talking with some people and naturally once people found out that I was a nurse, out came the usual "1001 questions to ask a stranger if you find out they are a nurse"

"Why does it burn when I pee?"

"See, I've had this boil on my butt for the past 6 months and..."

"is KY jelly the same as regular jelly? My boyfriend said it wouldn't make a difference and now..."

Ok. Ok. I was kidding about the quoted questions!

But they DID ask me a bunch of pointed questions. I could answer most of the "general stuff" (why is chronic high BP bad for you etc.) but dutifully told 'em that I couldn't give any medical advice for their respective issues and that they should follow up with their primary care physician.

The minute I said 'primary care physician', the subject changed abruptly. From that one discussion with about 14-18 patrons, I found:

1. A good minority didn't have a primary care physician. Granted these were mostly under the age of 30.

2. A VERY common complaint was the wait times to "get an appointment".

3. Complaint #2 was worse if the doctor being sought was a specialist.

4. A variant of complaint #2 was "My current doctor is an idiot/I am unhappy with services provided" and they are currently looking for a new PMD.

So the next day, I did a bit of digging around. I called a bunch of doctor's offices to see if they were accepting new patients.

4/8 were not accepting new patients at this time.

Of the 4 who were accepting new patients, 2 of them were a good distance away, and one of the closer docs didn't take my insurance.

I admit the results surprised me.

What are all these pts. supposed to do when they don't have a PMD and can't get in/see one in a reasonable amount of time?

Don't get me wrong - I totally understand that the ER's role is NOT primary care. I get that.

I'm not even bringing in complications such as "no insurance" etc (I had a buddy who ended up waiting almost 50 days before buddy could see a specialist and get an MRI done for debilitating migraines/headaches.) And we're not discussing people who don't have a doc because they didn't think they'd need one (for whatever reason - over sight, ill informed etc.)

Is access to primary care that desperate in our country?

The other reason I ask the question is because I follow medical bloggers online - and a bunch of the blogging docs are warning that with the way Govt./CMS is regulating practice and with falling compensation rates/insurance company hassles - primary care is no longer an attractive field for many med school graduates (here's an article from 2008).

So am I over-reacting to the whole thing or is there a legit issue here?

cheers,

[Freedom42]

I think access to primary care is a problem. I also think patients who fail to take responsibility for seeing primary care providers is another one.

I see plenty of patients who come to the ER because they say the hours are better (so why not come in at 3 a.m. to get that cold checked out); who assume it's faster and easier to get routine tests (cholesterol request at 4 a.m., no kidding); who never bother calling a PCP because it's easier to stroll into the ER; and who never use the number for the physician referral line that is given to every single patient at departure.

Where are they supposed to go? If they truly can't get access to a PCP, then they need to take non-emergent complaints to convenient care and quick care clinics whenever possible. I tell every patient with a non-emergent complaint that they can save a lot of money by going to a clinic. I tell them where they are, that they're open until late at night, and that they're open 7 days a week and on holidays. I often find myself doing encore performances of that presentation for those who don't get the message.

[Guest219794]

i think access to primary care is a problem. i also think patients who fail to take responsibility for seeing primary care providers is another one.

i see plenty of patients who come to the er because they say the hours are better (so why not come in at 3 a.m. to get that cold checked out); who assume it's faster and easier to get routine tests (cholesterol request at 4 a.m., no kidding); who never bother calling a pcp because it's easier to stroll into the er; and who never use the number for the physician referral line that is given to every single patient at departure.

where are they supposed to go? if they truly can't get access to a pcp, then they need to take non-emergent complaints to convenient care and quick care clinics whenever possible. i tell every patient with a non-emergent complaint that they can save a lot of money by going to a clinic. i tell them where they are, that they're open until late at night, and that they're open 7 days a week and on holidays. i often find myself doing encore performances of that presentation for those who don't get the message.

you have non-emergent pt's who pay?

[Freedom42]

It's an equal opportunity problem. People with insurance are just as much a part of the problem as those who are not fortunate enough to have it.

[ckh23, BSN, RN]

There is a predicted shortage of physicians in the future, especially PCP. The problem is/will be worse in rural areas.

[Gurmo]

I do think a lot of it is education. I mean many of these people don't know that the ED docs are not going to "follow" his/her case and make sure the meds we gave are going to work. I've found that some patients don't realize we are just going to make sure they are going to live but that a PCP will actually make sure the problem gets resolved.

[Roy Fokker, BSN, RN]

I do think a lot of it is education. I mean many of these people don't know that the ED docs are not going to "follow" his/her case and make sure the meds we gave are going to work. I've found that some patients don't realize we are just going to make sure they are going to live but that a PCP will actually make sure the problem gets resolved.

Excellent point!

I think I should clarify -- I'm also directing this thread AWAY from folks such as:

30 yr old female, G1P1. Presents with Chief Complaint: "I feel movement in my belly. Just like when I was pregnant".

No complaints of pain.

Wait. Scratch that! I should rephrase it:: "I hurt all over anyway since I have fibromyalgia. So when someone asks me what the pain level on a scale of 10 is, it's always atleast a 12. So when I have these movements in my belly, I can't tell if the pain is worse or not because I'm always in so much pain!"

States has tested positive multiple times on home pregnancy test. Had negative urine HCG and ultrasound at "rival hospital" which showed no indications for intra-uterine pregnancy. No bleeding or anything else untoward noted.

Person is convinced it's a gyn issue. Person is convinced that that ER doc and nurses just blew me off. No pelvic/gyn exam performed at last "ER visit" for the same complaint.

My question: "When was the last time you saw your OB/GYN?"

Answer: "Maybe about 3 years ago? I think?"

Me: "Are you on birth control?"

Answer: "Not really" [i [i]HATE[/i] answers like that! "Yes" or "No" damnit!]

Me: "Are you practicing safe sex? Are you or your partner using protection?"

I'll spare y'all the response!

My point with this post??

People seem to be 'genuinely ignorant' about "basic, preventative health care".

If a 30 year old Mother of a child can be so ignorant of "pregnancy symptoms", not be aware of regular medical/Gyn check up and follow up despite being advised to....

cheers,

[Anna Flaxis, BSN, RN]

My understanding is that yes, there is a shortage of PCPs. More and more med school grads are specializing because it is more lucrative.

There is also a lot of ignorance among our general populace. My own father, for instance, does not have a PCP. He says that since he is perfectly healthy, he doesn't need one, and that if he gets sick, he will walk in somewhere.

[Guest219794]

It's an equal opportunity problem. People with insurance are just as much a part of the problem as those who are not fortunate enough to have it.

Abolutely. Somebody's insurance status doesn't really matter. The question is whether the visit will cost them money. I rarely see a person come in with repeated nonsense visits if it costs them money.

So- an insured person with the type of insurance that allows free er visits, and an uninsured person with no plans to pay his/her bill are more likely to use the ER for trivial reasons.

An insured person with a significant co-pay, and an uninsured person who will be paying the bill are less likely to have a trivial visit.

[Sanuk]

I often daydream about the PSA ads I would write. Especially for those 2 am phone calls to my ER: "yes, I think my husband/wife is having a heart attack. What should I do?" Me: "Please hang up with me and call 911." Caller: "But we only live 12 miles away from your (tertiary) hospital. Is the ER open?" Me: banging head on counter.

I truly don't know why the general populace is so uninformed. It seems when I was a child, we never went to the ER. I could throw up for days before my parents even worried. Now, it's normal for parents to come running into the ER screaming that their child threw up ONCE. I honestly think a series of PSA's could do a lot of good.

And yes, we see it with insured and uninsured.

[sistasoul]

Sometimes you cannot get an appointment at your MD even if you are in pain. I had an earache last month and twice I could not get in to see my MD or any MD in that office. I went to a walk in clinic and the Doc wrote a script for ear drops. The drops made the pain worse. I made it through the night - this would be the second night with minimal sleep- and called my MD's office when it opened. I told the receptionist I was in a lot of pain and i was told there were no appointments with any of the MDs at the office. She said she would call me back after she talked to a nurse. I waited half an hour and then proceeded to the walk in clinic down the street for a second time. It turned out I had an ear infection and missed 3 days of work.

The walk in clinics in my area are not open overnight otherwise I would have went rather than suffering as I did not want to go to th ER. I always heard the ER nurses talking about how people were always going to the ER with ailments that should have been handled at their PCP's office. If that walk in clinic had not been open I would have went to the ED. I would not have had a choice as I could not wait any longer. I used to work as a receptionist in an eye Dr's office and I was told if anyone calls in for an appointment for pain, or if they see flashes of light o tell them to come right in. This may be why some people go to the ED- for a lack of being able to get in to see their MD.

[highlandlass1592, BSN, RN]

No you are not over-reacting. There is a huge shortage of primary/general care/family docs in this country. I have a primary, touch base with her every 6 months routinely. Now, have an actual issue I needed to see her for, 4 days I couldn't get in, she's got so many patients. I struggled for 3 weeks and found out after I've got a torn knee...am now looking at surgery.

I do all I can to try to stay healthy, take care of myself. I value my doc, she's great..but if I can't get in, it's just like not having one! And it's only going to get worse, the closer we get to full implementation of the health care law.