Gimme my healthcare, now!

[thinkertdm]

I just read an article about the rapid growth of "alternative" places of health service, such as telehealth, urgent care clinics, and retail health.  It also states that a very low percentage of the care delivered in the US is provided through these venues- I'd link to the article if I could, it's on Medscape.

My point of this is - is this a good thing?  There is a strong push to have people believe that health "care" is a right, having same day, if not same hour access is important, seeing a provider is important.  There is less and less impetus on self responsibility; the alternative venues do little more than pander to overly anxious people with syndromes that would most likely go away on their own.  However, their selling point (and one that I heard multiple times a day in my year of walk-in hell) is "what if".  We certainly can not diagnose pneumonia tele-anything, and can not rule out any differential that goes along with pneumonia, yet I am constantly told "televisits" are the wave of the future.   

The real magic of health care has been lost- that's the relationship - and trust- between a patient and the provider.  My first SP out of school was seeing grandchildren of children she had helped to to deliver.  She and her nurse knew when they called what needed to be seen and what could wait.

But now, OMG!  I NEED TO GET SEEN!!!1  by someone I have never interacted with, be told to take something I could pick up OTC.

Now that I think about it, I suspect that very few of these clinics practice real medicine and do absolutely nothing in the prevention of disease aside from flu shots.  In demanding instant healthcare but neglecting preventative health, you may get over your viral URI in a bit less time, but will still die from that MI looming.

One may argue that sure, they go see their PCP regularly but the "quikstop" for acute matters.  This is even worse, for it leads to fragmentation of care.  Neither provider A or provider B knows who is doing what.  And you can't see your pcp because they are crowded seeing baloney concerns that your mother would have said "it'll go away". 

Personal anecdote- I had some trouble breathing for a few weeks, so I went to such a place and was seen by a NP.  She didn't hear any wheezing, but gave me an albuterol inhaler and a Medrol dose pack to take if it didn't get better.  There were no labs or xray available because of the weekend.  I'm not sure what was on her differential, but she didn't ask about leg pain, recent surgery or recent travel (which were negative anyways).  I'm not a rocket scientist, but I have a feeling that steroid may have been bad for me.

A month later, with no resolution of the dyspnea, I was in the ICU with a massive PE.  An MD in an office setting with real tools at his fingertips who I had seen in the interim also did not catch it, but my point is this: maybe we, as an industry, slow down the rush to become retail and customer oriented.  "common things are common" only works most of the time, yet very rarely do I see any documentation of differential in notes I obtain from other providers for my patients. 

Ehh, back to work.  Thanks for listening.

 

[sas5814]

You touch on several good subjects. the first is prevention and personal responsibility. I'm old enough to remember NEVER hearing a health care provider mention lifestyle changes, weight etc. It was treat the disease in front of you. I think, while we still have light years to travel, we have made great strides in shifting from cure to prevention

Health care now (which ironically is the name of an urgent care chain) is just a reflection of our instant society and turning patients into customers. Cell phones with instant information and communication world wide. Computers thousands of times faster and more robust than just 5 years ago. Instant food of every kind (and some of it really good). Why wouldn't people expect the same from health care? It frustrates me as well. Just 2 weeks ago I had a patient complain because I couldn't obviate the laws of nature and make her flu ridden child fever free in 48 hours so she could go back to school. She couldn't even articulate WHY she wasn't satisfied but she was very sure about being dissatisfied. It is a mentality that doesn't help patient or provider.

I work in UC and we serve a couple of purposes and otherwise waste a lot of time and money. Because we are co-located with FP clinics we often backstop them when their schedules are full. We don't do all the FP things they do but we can reassure people, make good assessments of the patients condition and risk, and give them good advise. The other is intervention in acute problems some of which are potentially deadly. I can't count the numbs of "leg cramps" that were DVTs for example. In many cases without us the patient would have waited weeks to be seen by which time something bad may have happened.

Healthcare as a right is a concept that interests me. We haven't made food and shelter a right but healthcare, which arguably is often not a necessity, has become a right. Where is this right spelled out? I'm no constitutional scholar but I have never seen healthcare articulated as a right. Further confusing the issue is the majority of the people who claim it is a right are just yelling to be heard. I think its easy to argue it improves the quality and length of many people's lives but a right? If you don't get you child seen for his 24 hour old afebrile cold have your rights been violated? If you are denies care for lack of ability to pay have your rights been violated? If so why can't hungry people go demand free food from Walmart?

The government can claim it is a right (and I use the collective term government loosely) and then make it available by whatever means they choose. They cannot compel private enterprises to give away their services.If healthcare was a right then anyone entitled to it could take it and be backed up by the force of law. Can you imagine the government compelling you to care for people against your will?

Every place in medicine sees its share of misuse. UC and other primary care venues just have more than their fair share.

[kadiah]

I have this thought daily at work. I work at an UC that's attached with a FP clinic and I'm actively trying to get out because I just think Urgent Cares pander to a needy population. Todays been a light day - only 12 so far and only 3 of them actually needed to been seen - a laceration, a woman with a UTI, and a 6 year old who I caught a pneumonia (flu was also positive, so that was the cause). Everyone else was sniffles or 6 years of back pain ridiculousness. I give the sniffles their atrovent nose spray, tessalon, and "oh I know its rough when you sick" compassion.

 

But when I was young my Mom NEVER took me for a cold - heck I had a broken arm for 4 days before she took me. No one knows any kind of first aid care anymore - and the PCP office doesnt help because when patients call with 2 days of a runny nose they tell them to come to the walk in. 

Like Rev said, I'm here for catching DVTs/PEs/SAH... scary acronyms patients didnt even consider for their symptoms.. to make sure nothing falls through the cracks. But I find myself just getting more and more bitter when patients try to treat me like a Fast Food workers - they just are here to place their order and move along... and thinkertdm is right - it's due to everyone NEEDING instant gratification

[PAinPenna]

I heard somewhere recently that increasing access to care does not improve overall population health. This is evident in the corporate primary care office I have recently resigned from. Here, we have central schedulers at some call center (none of us even know where it is) just popping patients into any empty holes in the schedule, resulting in us full to the gills by that first screen refresh at 8:08 am or so. So , here you have first come first serve, 25 yo 2 day URI's that close out the schedule so we end up overbooking the fluid overloaded CHF-er that walks in SOB. In fact, all our oldest and sickest tend to walk in because they do not like to talk to a call center, so we end up having to accommodate them.  Our front office and nurses are exhausted, and our providers are fried.  I miss the connections I have made in my years in Family Medicine, but will never go back. 

[Cideous]

Our front office is required to perform the requisite wallet biopsy on all patients before I see them.  Welcome to Corporate Urgent Care.

[ventana]

The below came from a UVM email list that sums it up.  

 

Family Medicine community,

 

Sometimes it is easy to feel underappreciated and inadequate when comparing your knowledge to that of a specialist in a particular area.  I hope this recent JAMA Internal Medicine article will reassure you of the value you add to our patients lives every day!  

 

The punch line:  Every 10 primary care physicians per 100,000 population increases life expectancy by 51.5 days. That is huge and more than 2.5 times the population survival benefit of the same number of specialty physicians (19.2 days).

 

John

[Guest Paula]

I just left the corporate medicine world too and will never go back.  I'm starting in a private family practice clinic that is cash only and contract patients (employees and family members of businesses the clinic contracts with).  I hope it is better and start next week.

 

On a side note I had this thought that in 20 years or less we won't need stethoscopes or clinics or nurses, or labs or tools of the trade.  We will just need to go to a kiosk and an assistant (a PA) will stick an electrode on your chest and there will be an instant read out of an EKG, Chest xray, labs, scan of your brain and arteries, check for the DVT, check the B/P and temp, check for the triple A, and all the other things that could go wrong.  Anything that is wrong you will get a ticket and go stand in line like you do at the DMV or Social Security office and then be seen by the "doctor".  Not sure who that will be...…..Dr. George Jetson, I guess.