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GRAY MATTERS: Access to Physicians

SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

None of the proposed health reforms will fix one of the most troublesome problems for patients and their families – reaching a doctor after hours or on a weekend. That’s a major reason emergency rooms are packed at night and on weekends with sick and feverish people in great distress and getting sicker.

And that’s not going to get better anytime soon. According to the American Academy of Family Physicians, there is a shortage of primary care physicians and it’s likely to get worse in large part, ironically, because the health insurance reforms will increase access to care when there will be fewer family doctors to provide basic and timely care.

Even now if you really need your doctor, after, say 4PM, it’s likely you will get this message: “If it’s an emergency, hang up and dial 911...or call 555-4444 and ask for the doctor on call.” In that case, while you’re waiting anxiously, if or when he or she calls back, you will be told to go to the emergency room anyway.

It used to be that you could get your doctor on the phone to ask his or her advice. Or there was a time when your physician, who you assumed was primarily responsible for your care, would meet you in the emergency room to see to your needs, or at least call ahead (as one of my doctors did a few years ago) to clear the way through triage.

No more. Now you’re passed, like a buck, to the emergency room physician on duty or to a “hospitalist,” your doctor’s designated hospital representative, neither of whom ever laid eyes on you.

It’s difficult to get through to your doctor even during office hours (“Your call is important to us”). And it used to be that you did not take a crying child running a high fever out in the cold. Now you have no choice. It’s either a walk-in clinic, where you may have to pay cash, or the emergency room.

I’m not blaming doctors or the medical profession. We all have our doctor stories but today, beleaguered physicians as well as patients have become the prisoners, or victims, of corporate for-profit medicine and the demands of insurance companies (including Medicare and its regulations).

Doctors work under great pressure, accepting too many patients, often in large practices owned by a corporate entity, trying to keep up with the latest drugs and developments, and dealing too quickly with each patient no matter their needs. Many abandon individual practices that they can’t afford for multi-physician specialties that operate like factories. And although they have lives in their care, most don’t get rich. Last time I looked, doctors earned on average about $200,000 a year, nowhere near what a Wall Street trader makes for producing nothing.

No wonder thousands of doctors, including most of my own, favor single-payer national health insurance. Not surprisingly, a survey last year by the University of Indiana School of Medicine found that support for such a system was particularly strong among emergency physicians (69 percent), pediatricians (65), and family doctors (60).

“Across the board,” said Dr. Ronald Ackerman, who helped direct the survey, “more physicians feel that our fragmented and for-profit insurance system is obstructing good patient care.”

I’d go further; under these circumstances, present patient care can be downright dangerous or frightening especially or if you are really in trouble or you’re older, like me. I don’t ordinarily become personally involved in these columns, but permit me to cite a couple of my recent experiences, because they are not untypical and relevant.

On a Friday evening, a usually routine urological procedure which many older men undergo, went awry with bleeding. Stuff happens. But the doctor’s office was closed and the emergency room –where the wait was less than an hour – was the only recourse. Further complications, included blood clots in the catheter and great pain, which mean a night in the hospital attended by strange doctors. And there were two more night time trips to the emergency room that week.

The surprised urologist was dismayed by my problems and shocked that I had to wait hours in the emergency room for help, but he did not come to the hospital to see to my care. One of his nurse-practitioners told me later, “We can’t be on call 24 hours for every patient.”

Actually, I’m told by a doctor friend, they are responsible for my care – for 24 hours or however long it takes. The total bills, for Medicare and my secondary insurer will come to more than $8,000.

One more story about the same time: As some of you may know, I am a survivor (nearly five years) of esophageal cancer. But during my last checkup, my oncologist suggested a new endoscopy to find the cause of some internal problems. That was done in early November by the gastroenterologist who had discovered my cancer in 2005, and he reported finding “causes for concern.”

He ordered biopsies, the results of which, he said, would not be available for nearly two weeks. Why so long? There were others ahead of me, he said. The doctor’s report would be available via phone recording, but not for two weeks.

You can imagine my anxiety, especially because the oncologist reading the initial report sent me an email suggesting one possibility was a recurrence of the cancer. But he too was puzzled by the long wait for the biopsy results. And in response to my pleas, late on a Friday afternoon, he reached the gastroenterologist. The biopses were available – and negative; apparently I had had a mild stomach inflammation.

Why hadn’t he let me know sooner? When I complained, he told me he had been busy with other patients. “The ideal is not always achievable,” he wrote. “I got no call of alarm from the pathologist about you.” So it was not necessary to call. He had 100 patients and could not notify all of them, he said.

National health insurance, if it ever comes, will not solve all such problems in modern medicine. But perhaps it may relieve the pressure of having to make enough money to support large factory-like practices so a urologist and gastroenterologist could pay closer attention to their patients. When you are too busy to do that, you are too busy.

A similar experience to ask about? Write saulfriedman@comcast.net

Comments

You have invited all to send you their stories of medical/health care abuse or neglect...you are a brave man Mr. Friedman. Wading through all of those messages would have me depressed in no time at all.

But, your post reminded me of a thought I once had, that it would be great to have an internet site where people could write about their health care experiences. The data that they entered could be sorted by city, state and the physical complaint. Of course there should be a field to enter the name of the insurance carrier as well as the doctor. Then, a monthly report could be sent to the State and Federal lawmakers as well as the AMA, the Governors and the President. Every month, a report with all new data from that month plus a total for the year. It would be the peoples voice...

Just an idea...

And the opponents of a single payer system have the nerve to say that in such a system people would have long waits. Makes me so mad I could bite nails. We have been sold out to the insurance compoanies.

A couple of thoughts: I've mentioned to a couple of physicians that they are a powerful group (AMA)who could bring pressure on 2 other groups who've really mucked things up: big Pharma & health care insurers. All declined to acknowlege this & claimed that they were also victims of the systems! Right. And yet when medicare was in the process of becoming a reality, generally most doctors were mightily opposed.
The other thought I have is that after practicing as an RN for 40+ years, I've discovered that nurses no longer pick up much of the slack for physicians. I can recall making many, many timely phone calls (from the ER mostly)to check on patients, to advise them of results of x-rays & blood tests, etc. Often with just a few words of reassurance & advice, problems were avoided. But try to find a practice nowdays that even employes an RN......."medical assistants" are cheaper & I might add much less educated & experienced than RNs. And I'm not the only nurse (retired & working)who feels this way. Dee

We need to change the entire practice and training of doctors. There's absolutely no reason doctors should be in short supply. Or cost 300K to train.

Many of the tasks could even be done by Nurse Practitioners or even trained Paramedics. It's ridiculous that we've let this profession become so full of highly paid specialists instead of having a true triage system FULL of GPs to take care of all the simple things and free up the specialists to take good care of their patients.

Not to say that getting emergency medical care isn't a huge problem many places, but I wonder how this differs regionally. I have had cause to need "urgent" care when new to a town, on a weekend at home, and away from home. The issues were a cut needing stitches, an infected skin abrasion, a blood test, a urinary tract infection, and follow up. All were dealt with at an "Urgent Care" facility variously in No. Calif, Iowa, Mississipi, Missouri and Texas. I understand that such places are not universally available. I think that they are usually owned by one or more doctors and are staffed by doctors, P.A.s, Nurses, etc. Perhaps the existence of these resources isn't widely known, so that's why I'm mentioning my experiences here. Of course, It SO helps to have Medicare, as I imagine private carriers may impose restrictions. I've had to "co-pay" a little sometimes, but every different experience has been positive. (I'm glad to be able to bring a positive experience to the discussion.) I feel lucky to have had access to medical attention after hours and in strange places. Why not have these places everywhere??

Our family doc would examine me, give me the usual lecture, and invite me into his office. There he would bum a cigarette and under the guise of being social, would find out more about me. Or I about him.

I am fortunate enough to have a caring primary care physician, but I fear he will be 'burned out' soon. I have to wait a normal 2 hours after my appointment time before being seen because he is caring enough to take time to really find out what is wrong with his patients. One time my appointment was for 3 pm and I finally got in to see him at 6 pm. He took a full hour with me because I had some puzzling issues. His nurse drove me home at 7 pm because it was too late for me to get a ride. I asked her if this was a normal day and she said 'yes'. However, they do shut the phones off at 4 pm and you get voice mail.

He also visited me in the rehab center after he accidentally found out I was there. He is a rare breed who is trying to really care for his patients and it is costing him dearly. Our system is really mucked up.


He is a rare doctor trying to take care of too many patients and practicing old fashioned medicine. He also knows me when he enters the examining room; something my previous doctors did not.

This is the good side. I could write a book about the bad experiences. I will e-mail you, Saul, with a couple of examples.

We have urgent care in our area of Wisconsin. Our insurer also provides a toll-free "nurse on call" source for information and referrals. I've used that several times after hours, to determine whether or not it's something that needs to be addressed. I even used it once when I questioned what the ER doctor told me to do. I was able to use that information to get into a specialist right away rather than the wait-and-see from the ER doc.

I remember another time being told to go to the ER, and by the time I got there the nurse had called ahead and started the process so we got in right away.

I think quality of care is dependent on a lot of things, a big one being location.

Steven--There are web sites on which one may evaluate or read evaluations of physicians. The one I use is
Vitals

It reduces healthcare costs to use Physician Assistants or Nurse Practitioners, where available. I routinely see a PA for dermatalogical needs, including removal of a basal cell carcinoma on my face (5 years ago, "my" PA had suggested that I see a plastic surgeion because of the location, but I insisted that she remove the carcinoma right then and am extremely pleased with the results), not having seen an MD for such needs for at least 20 years.

State of healthcare is such I don't hold out much hope for improvement until we have a serious change in our for profit system. Until power and control is removed from pharmaceutical companies and insurers, instituting effective change will be limited.

I've had well-meaning timely treatment, mixed quality, with urgent care in my community and where I've visited. There has been reduced use of RNs with increased use of lesser trained medical nurses often expected to provide services beyond their knowledge level -- caring for older people, especially.

I have grave reservations about the level of care patients may receive in acute hospitals if their own personal physician doesn't follow their case and see them there.

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