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

[Roy Fokker]

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,

[merrywhiterose]

There are less PCPs however there are more nurse practitioners & physician assistants. PCPs can give advice via teleconferencing to more than one office. This is the wave of the future. There will always be people that choose to not get medical help. There are also those that don't have insurance so don't seek it unless they absolutely have to. Then you have the ones that have Medicaid/Medicare that abuse the system & go to the ER for a sore throat, and if it's not covered by their insurance, they simply won't pay. I'm not sure what the anwer is.

[traumarnrodney]

I work triage A LOT, and the majority of what we see (at least 80%) could have been seen by primary care or minor med with the same outcomes. I agree 100% with the argument that co-pays are the way to stop a majority of ER abusers. The ones that come in for every sniffle or cough are the ones who pay NOTHING for their care. There should be a minimum $50 fee for nonemergent conditions. Pay or go to your pcp.

[ZippyGBR, BSN, RN]

yet another case where the 'inferior' socialised systems prove that they are in fact better;

same day urgent primary care appointment - yes not a problem

a routine appointment with one of the primary care docs at the practice sometimes in the next couple of days - not a problem

a routine appointment with a named Doctor at the practice - might be next week

advice or clinic appt or home visit ( if clinically indicated) out of hours - at the end of the phone.

misuse the ED out of hours - get redirected to the OOH primary care clinic

away from home ? pop to a walk-in primary care centre ...

all free at the point of delivery and all prescriptions (if you aren't one of the many exempted groups ) just 7. 20 gbp each ...

[mwboswell]

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 .

Your auto insurance covers your medical evaluation and treatment at time of injury not medicare.

1 rule of medicine: don't do the test if it doesn't change the treatment. In other words if you already know what you're going to do to treat the patient, then the test is unnecessary. Unless they thought "fractures" they wouldn't bother with the tests. Too many times tests are done just to appease patients. (just like un-necessary Rx's for things like "sinuses" [no abx indicated for sinuses first line])

-Mark Boswell

MSN FNP-BC CEN CFRN CTRN CPEN NREMT-P

"Support CEN Certification and Your Local ENA"

[Ruby Vee, BSN]

i have a primary care doctor; i've been going to her for years. over the past three years or so, however, she's been increasingly unavailable for anything but the annual check-up scheduled months in advance. i've been to the local "doc in a box" more often than to my pcp in the past year -- she's just not been available. and now i've gotten a letter from her informing me that she's going into "private practice" (gee -- i thought that's what she already did). for $1600 a year, i get an annual exam and 11 visits. but she won't be taking insurance -- any insurance. so it's cash upfront. not $125 at the time of the visit but $1600 on january 1 or she won't see me.

so i'm shopping for a new pcp. the ones that colleagues have recommended aren't taking new patients. so either i just blindly pick someone or i keep shopping for awhile. in the meantime, what do i do? guess i'll just keep going to the doc-in-a-box.

[Lunah, MSN, RN]

Ruby, one of the more popular practices near my old ER did the same thing a couple of years ago -- you had to cough up something like $1200 or $1400 for the privilege of remaining as one of their patients. It really hurt a lot of our older patients who had been going to these docs for years, who were suddenly without primary care. And those docs STILL couldn't admit to the hospital, they still had to use hospitalists! But they'd sure walk in the ER like they owned it. Really made me grit my teeth ... grrrrrr.

The Army is having a tough time serving its population as well ... as usual, the ER bears the overflow from the primary care providers or the Troop Medical Clinics. I always ask if they've called for an appointment or followed up (or both, if applicable), and usually the answer is yes, but they couldn't get in. Based on my own experience, I believe it.

Funny conversation ... a patient was complaining about waiting in the ER waiting room for 2 hours. Our unit secretary said, "Did you try to get in to see your primary care manager?" The response was yes, but the PCM couldn't see her for two weeks. So our secretary, offering a wonderful bit of perspective, said, "Then doesn't two hours seem like a pretty good deal to get seen?" Hahaha.

[Trekfan]

Your auto insurance covers your medical evaluation and treatment at time of injury not medicare."

I did not know that at the time but I do now .I went to work and was yelling out ouch all morning (witch I never do) and after being on the phone with both insurances and my alflac . I was told to go back to the doctor and they would cover it that doctor then sent me back to the ER (not the same one this time ) turns out I have some nerve damage However I still had to pay for some of the care first and then be payed back (I hope) Boy this is the most confusing thing I have ever had to deal with

[Trekfan]

i have a primary care doctor; i've been going to her for years. over the past three years or so, however, she's been increasingly unavailable for anything but the annual check-up scheduled months in advance. i've been to the local "doc in a box" more often than to my pcp in the past year -- she's just not been available. and now i've gotten a letter from her informing me that she's going into "private practice" (gee -- i thought that's what she already did). for $1600 a year, i get an annual exam and 11 visits. but she won't be taking insurance -- any insurance. so it's cash upfront. not $125 at the time of the visit but $1600 on january 1 or she won't see me.

so i'm shopping for a new pcp. the ones that colleagues have recommended aren't taking new patients. so either i just blindly pick someone or i keep shopping for awhile. in the meantime, what do i do? guess i'll just keep going to the doc-in-a-box.

a gyn doctor around here did the same thing , i can not blleave that there are people that would just walk in and pay that kind of money . your doctor is cleaning up she is getting !1600.00 one visit because you will never get back in .

[mwboswell]

Absolutely!

I just heard not too long ago (might have even been on this BB),

The reason people will wait 6-8-10 or more hours in an ED to be seen is b/c it's NEVER as long as the wait for an actual doctor's appt in an office!

-Mark Boswell

MSN FNP-BC CEN CFRN CTRN CPEN NREMT-P

"Support CEN Certification and Your Local ENA"

Ruby, one of the more popular practices near my old ER did the same thing a couple of years ago -- you had to cough up something like $1200 or $1400 for the privilege of remaining as one of their patients. It really hurt a lot of our older patients who had been going to these docs for years, who were suddenly without primary care. And those docs STILL couldn't admit to the hospital, they still had to use hospitalists! But they'd sure walk in the ER like they owned it. Really made me grit my teeth ... grrrrrr.

The Army is having a tough time serving its population as well ... as usual, the ER bears the overflow from the primary care providers or the Troop Medical Clinics. I always ask if they've called for an appointment or followed up (or both, if applicable), and usually the answer is yes, but they couldn't get in. Based on my own experience, I believe it.

Funny conversation ... a patient was complaining about waiting in the ER waiting room for 2 hours. Our unit secretary said, "Did you try to get in to see your primary care manager?" The response was yes, but the PCM couldn't see her for two weeks. So our secretary, offering a wonderful bit of perspective, said, "Then doesn't two hours seem like a pretty good deal to get seen?" Hahaha.

[VICEDRN, BSN, RN]

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 a.

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.

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,

Think its brilliant that you actually called around. I was recently surprised at how long it takes to get a "new patient appointment" here in my area and all I did was change insurance plans.

I have also talked to the patients about their follow ups. (I'm curious.) Honestly, I think the answer is better coordinated care. Lots of the patients are willing to wait to see ortho for MRI or neuro for follow up for vertigo but we don't give them enough meds upon discharge. Of course, there is the possibility for abuse but if we don't give them meds, they just re-visit on their legitimate pain complaint.

Will also add that I talk slow and LOUD when I get to the part about "AND you have THIRTY days of meds here for your blood pressure so you should CALL and make an appointment TOMORROW first thing to see the PCP, right? RIGHT!"

As for the med school grads, unfortunately, I think the problem is that we need to recruit more people into medical school that actually want to serve the public rather than themselves (or more aggressively set limits on student loan repayment by service plans). Let's not forget that their residencies are funded with our medicare dollars and the number of residents in each specialty is supposed to reflect the actual needs of our country. At the very least, I don't really care for the fear mongering attitude thrown off by docs like that.

[Armygirl7]

from royfokker "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....?

roy i really think this is key - maybe some mandatory yearly health education in the public schools about managing your health care in the real world - not like health class where you see the birth film and some kid always passes out or barfs!

more like a modernized home ec class - learn how to cook and feed yourself for good health, learn how to balance a checkbook, save money, and learn how our healthcare system works and how to manage it, what's an emergency and what isn't, and what our civic responsibility is in relation to that...that coupled with some strong psas as another poster mentioned and a push by med schools to recruit more pcp-interested students....oy...there's always so many layers to a problem!!

great thread - thanks.

[VICEDRN, BSN, RN]

from royfokker "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....?

roy i really think this is key - maybe some mandatory yearly health education in the public schools about managing your health care in the real world - not like health class where you see the birth film and some kid always passes out or barfs!

more like a modernized home ec class - learn how to cook and feed yourself for good health, learn how to balance a checkbook, save money, and learn how our healthcare system works and how to manage it, what's an emergency and what isn't, and what our civic responsibility is in relation to that...that coupled with some strong psas as another poster mentioned and a push by med schools to recruit more pcp-interested students....oy...there's always so many layers to a problem!!

great thread - thanks.

sounds goofy but this is one of my daydreams. doing basic health teaching to public school kids. i feel like every one should know anatomy and everyone should have some basic health knowledge. makes me all mushy thinking we could save our little health system with some simple self awareness and basic health education.

the first health education i got came from an np during my first bachelors. i was so surprised...didn't know clear fluids would help me drain my sinuses and that bed rest clear fluids and some sudafed could prevent infections from setting in! 19 years old and no one had explained all these connections to me yet!