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?
I just posted something on another thread about this :
When I called pcp for an apt. I was the next one was in 3 months ! Sence the Nurse said it could not wait the doctor and nurse and staying late to see me but I still have to wait 2 weeks now that.
Last year I was refured out of state to another hospital. I was so sick I thought I was going to die the hospital was abale to get me an EMERNCEY apt. And I still had to wait 2 months :eek .
I used to work for a PCP; he absolutely hated Family Practice.
This Doc regretted not specializing & having the same "Chronics" keep coming back; but when you specialize, you treat them, then send them back to their PCP.
I believe there is a genuine shortage of primary care providers in many areas, particularly those who accept Medicare & Medicaid. I've been begging my own parent, who is now aged 60+ to find a new PCP, as the current one has been very clear that she does not accept Medicare patients.
However, ... I believe this accounts for only a very small percentage of ER use. I've worked in an ER in a very affluent area, full of well-insured people who rattled off the name of their PCP as if he/she was a close friend/golf buddy (and sometimes was). But when I was triaging a (very) minor complaint and asked if the patient had contacted PCP-buddy ... I often got the "are you stupid?" stare in response, or, on one memorable occasion, the comment, "I did call the office, but the times they offered me were not convenient." My point? Access, and the means to pay upfront for an office visit, do not magically produce the desire to appropriately use resources.
Prescription refills: by definition, anyone in possession of an Rx for some maintenance med must have seen a provider "on the outside" at least once, right? So let's do the math: if on September 1 I got my last refill of my daily med X and there are 30 pills in the bottle, and a train leaves Chicago at the same time ... on what day will I take my last available pill and need another Rx? Based on that answer, on what day should I call my PCP for an appt so that I can be seen in time to obtain another Rx without interrupting my daily med regimen? This is not rocket science, but it does take some planning. I don't see much evidence of planning where I work ... do you?
Follow up with your doctor. Duh, again I get the "are you stupid?" stare. Follow up is for sissies, and (yes, I have been told this) "if you people really knew what you were doing, I wouldn't have to follow up to make sure I was better because you would have fixed me in the first place". :flmngmd:
Health maintenance requires the ability to plan ahead, allow for the unexpected, and accept the relative frality of the human body. I don't see too many who exhibit these behaviors, neither among the homeless and transient, the very affluent, nor in the vast masses of people in between.
Well said, Altra. I think that we live in a society so accustomed to instant gratification that many of us assume we are entitled to instant treatment for any problem. Wait? You've got to be kidding.
Last month, I was asked to discharge a young woman who had come in describing horrible abdominal pain. Oh, and her period was two days late. Of course, she got the full abdominal workup. But, dear reader, do you really think that she came in for abdominal pain?
"The doctor wants you to take a home (emphasis doc's) pregnancy test every other day until you get your period," I said. "If that persists for more than three days, you need to see your own doctor."
"What if I don't get my period tomorrow? Can I just come back?" the patient replied.
"If that's the case, he would like you to take a pregnancy test at home," I said (emphasis mine), swiftly moving onto what I anticipated would be the next element of protest. "The good news is, you can pick up a home pregnancy test at the Dollar Store for a buck. A lot easier than coming back here."
"Oh, come on," she said, picking up her Koolata and heading for the door. "That's so expensive."
She left. Without a trace of irony. Apparently, an ER visit that cost in excess of $1,000 -- to everybody but the patient, I guess, but that's another thread -- well, that's cheaper than schlepping over to the five-and-ten and shelling out a buck. Moments later, I was sent to triage a young woman whose chief complaint was headache -- oh, and by the way, she hadn't had a period for six months, she'd taken a home pregnancy test, and she'd confirmed she was pregnant. Now her family thought she ought to get "checked out" to make sure everything was OK. On a Saturday night at 8 p.m.
"Happy to help you with your headache," I said. "But you really need to see an ob-gyn for prenatal care."
"Oh, I know that," she said, exasperated by the stupid nurse. "But I'm here now. So let's get it done."
Indeed. We achieved the trifecta that night when a young woman came in describing all of the symptoms of a stroke -- except that she appeared perfectly fine and, when questioned, acknowledged that the timeline of her story did not add up. Nonetheless, the physician prudently ordered a CT scan. Of course, as soon as the result of her pregnancy test came back -- results she asked for repeatedly -- she no longer needed the CT and asked to leave. It was a miracle! In the time it took for a technician to be called in on weekend overtime for the procedure, her symptoms -- the excruciating headache, the facial numbness, the pain in her neck -- all vanished as quickly as they (allegedly) came.
Every ER nurse on this board has got a gazillion stories like those. Primary care provider shortage? Yes. But many of these people don't know anything about that, nor do they care to. They just know that they want what they want, regardless of how illogical it might be, and they want it when they want it, regardless of who has to pay for it. Unfortunately, the system complies -- and we all pay the price.
Specializes in ER, Trauma, ICU/CCU/NICU, EMS, Transport.
However, some of those "refills" (non schedule II) can be refilled up to a year depending if the PCP writes refill x12. I'm guilty - I haven't seen my PCP for over 9 months now, and I'm still using the same refill monthly PPI Rx.
So a current Rx doesn't nec mean they have seen a MD for some time.
-Mark Boswell
MSN FNP-BC CEN CFRN CTRN CPEN NREMT-P
"Support CEN Certification and your local ENA"
This is a multi-faceted problem.
I believe there is a genuine shortage of primary care providers in many areas, particularly those who accept Medicare & Medicaid. I've been begging my own parent, who is now aged 60+ to find a new PCP, as the current one has been very clear that she does not accept Medicare patients.
However, ... I believe this accounts for only a very small percentage of ER use. I've worked in an ER in a very affluent area, full of well-insured people who rattled off the name of their PCP as if he/she was a close friend/golf buddy (and sometimes was). But when I was triaging a (very) minor complaint and asked if the patient had contacted PCP-buddy ... I often got the "are you stupid?" stare in response, or, on one memorable occasion, the comment, "I did call the office, but the times they offered me were not convenient." My point? Access, and the means to pay upfront for an office visit, do not magically produce the desire to appropriately use resources.
Prescription refills: by definition, anyone in possession of an Rx for some maintenance med must have seen a provider "on the outside" at least once, right? So let's do the math: if on September 1 I got my last refill of my daily med X and there are 30 pills in the bottle, and a train leaves Chicago at the same time ... on what day will I take my last available pill and need another Rx? Based on that answer, on what day should I call my PCP for an appt so that I can be seen in time to obtain another Rx without interrupting my daily med regimen? This is not rocket science, but it does take some planning. I don't see much evidence of planning where I work ... do you?
Follow up with your doctor. Duh, again I get the "are you stupid?" stare. Follow up is for sissies, and (yes, I have been told this) "if you people really knew what you were doing, I wouldn't have to follow up to make sure I was better because you would have fixed me in the first place". :flmngmd:
Health maintenance requires the ability to plan ahead, allow for the unexpected, and accept the relative frality of the human body. I don't see too many who exhibit these behaviors, neither among the homeless and transient, the very affluent, nor in the vast masses of people in between.
Specializes in ER, Trauma, ICU/CCU/NICU, EMS, Transport.
Back to the OP (Roy)....
Lots of issues here. Here's my personal observations on a few points....
Yes, problem with access for both insured and uninsured, BUT, I have seen different communities with different solutions.
In my current community, we have 5 local "free clinics" for the uninsured. granted you have to show up at 10am and wait in line, but you do get a "primary" doctor "home" to follow your chronic condition. I have seen HUNDREDS of patients that use this system reliably and responsibly for their chronic conditions (HTN, DM, Chol etc, etc)...AND because it's a "free" clinic for uninsured, they also have a on site pharmacy AND specialists (a few) will rotate through there monthly (all staff: clerks, med techs, nurses, md's are VOLUNTEERS). Also if the pt needs some labs or specialty testing, the free clinic is plugged into the big hospital system here and have arrangements to get testing (MRI, CT etc) at a reduced or charity rate.
Our community also has a couple of "faith based" free clinics too that work similarly - it is a "mission" work for a couple of big churches.
We also have some middle-of-the-road clinics where the fees are based on a sliding income scale, kinda like for the "working poor" -they operate similar to the free clinics.
I must note that all the above are funded substantially by charity grants, foundations, corporate donations, individual philanthropists and community organizations such as United Way (think about that next time the United Way campaign comes to town!)
Another part of the problem is as one poster said "I'm healthy, I don't need a Dr" (even though they have insurance)....Yep I can see that, but this is where education needs to come in. They need to know about health maintenance (at ANY age), as well as just having a Dr so if you need something, it's not like starting from scratch. Also with a good PCP, sometimes you don't need an appt - just aphone call will do sometimes. Maybe an Abx call in Rx, or some advice if they need to go to ER or not; things like that - but you GOT to have that relationship first.
Oh, and while shopping for a PCP; it's a VERY appropriate question to ask at your first visit about will they do same-day or next day work in visits for acute problems. You need to know this when you start going to a MD as this becomes your alternative to the ED for non-life-or-death problems. A "good" MD, will have some time each day left open for call ins or work ins. Or if your "good" MD is with a group of Md's in one practice, then each day one of them may only schedule for half a day and leave the rest open for "ESTABLISHED" patients of the group practice.
I believe there is a genuine shortage of primary care providers in many areas, particularly those who accept Medicare & Medicaid. I've been begging my own parent, who is now aged 60+ to find a new PCP, as the current one has been very clear that she does not accept Medicare patients.
However, ... I believe this accounts for only a very small percentage of ER use. I've worked in an ER in a very affluent area, full of well-insured people who rattled off the name of their PCP as if he/she was a close friend/golf buddy (and sometimes was). But when I was triaging a (very) minor complaint and asked if the patient had contacted PCP-buddy ... I often got the "are you stupid?" stare in response, or, on one memorable occasion, the comment, "I did call the office, but the times they offered me were not convenient." My point? Access, and the means to pay upfront for an office visit, do not magically produce the desire to appropriately use resources.
Prescription refills: by definition, anyone in possession of an Rx for some maintenance med must have seen a provider "on the outside" at least once, right? So let's do the math: if on September 1 I got my last refill of my daily med X and there are 30 pills in the bottle, and a train leaves Chicago at the same time ... on what day will I take my last available pill and need another Rx? Based on that answer, on what day should I call my PCP for an appt so that I can be seen in time to obtain another Rx without interrupting my daily med regimen? This is not rocket science, but it does take some planning. I don't see much evidence of planning where I work ... do you?
Follow up with your doctor. Duh, again I get the "are you stupid?" stare. Follow up is for sissies, and (yes, I have been told this) "if you people really knew what you were doing, I wouldn't have to follow up to make sure I was better because you would have fixed me in the first place". :flmngmd:
Health maintenance requires the ability to plan ahead, allow for the unexpected, and accept the relative frality of the human body. I don't see too many who exhibit these behaviors, neither among the homeless and transient, the very affluent, nor in the vast masses of people in between.
loved your post , and I think you are right to the tee.
Okay so unfortunately I got a firsthand experience with the Medicare /Medicaid system:uhoh3: we are talking about . I was in a car accident this morning a man hit is from behind so hard that the inside of the car fell apart . right after the accident I realized that I had hurt my shoulder and I couldn't feel my arm or my hand at all I called my PCP and I was told to go to the emergency room as there wasn't really much they could do at the office . so after going to the emergency room someone came up to me and told me that Medicare did not cover car accident:confused: :confused: So am I supposed to do what now ???
I did later get to see a doctor but Thay would not do any x-rays because "wait for it " thay would show I have damage to my neck ,back, and shoulder .
Ok I am no doctor but is that a good reason to do x-rays ???? I was told to call my pcp if i still could not fill my hand in two days ??
I can not help but think if I have had blue cross I would have gotten better treatment .
I'm sorry you had that experience. Medicare does cover car accidents. I don't think anyone on this thread would question the appropriateness of your going to the emergency department under the circumstances of an accident.
Great thread. I agree most pts use the ER as a same day appt office. I work in a family planning office and have had pts tell me they went to the ER for yeast inf, irreg periods, heavy periods. I try to expl that the ER is for EMERGENCIES. They answer -but I couldn't get an appt in the clinic this week : (
My point? Access, and the means to pay upfront for an office visit, do not magically produce the desire to appropriately use resources.
I called my PCP and I was told to go to the emergency room as there wasn't really much they could do at the office . so after going to the emergency room someone came up to me and told me that Medicare did not cover car accident:confused: 
:confused:
Trekfan
466 Posts
I just posted something on another thread about this :
When I called pcp for an apt. I was the next one was in 3 months ! Sence the Nurse said it could not wait the doctor and nurse and staying late to see me but I still have to wait 2 weeks now that.
Last year I was refured out of state to another hospital. I was so sick I thought I was going to die the hospital was abale to get me an EMERNCEY apt. And I still had to wait 2 months :eek .