US healthcare, wait times and the truth…

It’s time for another post on truth and healthcare. (This almost sounds like a good series.)

I’ve recently written that the VA healthcare system represents the truth—and that Americans should get over the Pollyanna view that triage, wait lists, and taking care of increasing numbers of increasingly sick patients can be managed with magic.

The truth to be discussed in this post is that long wait times and challenging access to care is already here. And that such is normal. If you have been a patient lately, you may already know this.

One of the most common e-notes I get from my medical assistant reads like this:

“Referring Dr. X has a patient (often, Mr. CEO) with atrial fibrillation, and she wants you to see him in 1-2 weeks. Your next appointment slot for a new patient is 3 months. What should I do?”

This is a problem. Maybe you have a solution?

Here is what happens in the real world. I look at the chart. If this patient has no emergency (AF is rarely an emergency), he gets put in the first available slot. That means he waits.

(The irony of AF care is that as long as his referring doctor has begun the nominal things, such as rate control, stroke prevention and lifestyle interactions, it’s not uncommon that the arrhythmia resolves by the time I see him.) Time is such a powerful disease fighter.

The other truth about American healthcare is that if this patient is “connected,” let’s say he knows me, or his referring doctor advocates for him strongly, perhaps by calling me personally, then maybe the schedule can be juggled and I can see him sooner. Maybe.

The problem with that maneuver is that moving a new patient in means rescheduling another patient back, or adding another patient to an already full list. And at first glance, the latter solution seems simple—just see the extra patient, work harder, stay later, turn up the treadmill speed faster.

Well. Prepare for more truth.

The truth is the speed of most doctors’ treadmill is already close to or at maximum. The analogy here is when cross-country parents yell at their kid to catch up to the kid running just in front of theirs. It’s a pointless exercise because if the kid could be up there, she would. It’s the same with doctors. We really can’t go any faster. Well, that is, if we don’t want to cut the course and cheat. Sure, we could see more patients by providing paternalistic uninformed care. We could make a quick diagnosis and write a prescription, offering only, “take this.”

But if the aim is to provide true quality of care (not checkbox quality), and to allow for shared decision-making in well-informed patients, and to then take the time to document said care for other members of the team, our speed must decrease not increase. We must see fewer not more patients.

Healthcare done well moves slower, not faster.

My situation is instructive. I don’t have the luxury of a nurse practitioner or physician assistant. It’s just me, and a talented medical assistant.

When I see an AF patient, we often have to start from scratch: What are the symptoms? Are the symptoms related to the AF? What are the other illnesses? What are the patient’s goals for care? What does the exam and previous tests show? These are the easy parts. Next is the explanation. We have to remove fear, explain stroke prevention in probability terms, discuss heart failure risk and determine the pros and cons of attempting rhythm control. And then, which rhythm control approach—drugs, cardioversion, ablation, or some combination.

This takes a minimum of 30 minutes, ideally an hour or more. In the old days, I could then send a one-page letter to the referring doctor, which took two minutes. Now, I tap and click and dictate through an electronic record (fraud-protection invoice) for many minutes. That’s not a complaint, just a fact.

Elizabeth Rosenthal is a New York Times reporter who is writing a series about the high cost of US healthcare. This weekend she wrote a truthful piece about the long wait for care in the US. It’s an important read because she dispels the myth that the private and competitive US system provides more timely care than other nations. Ms. Rosenthal quotes studies that show wait times in the US are barely better than Canada, and worse than countries with national health systems such as Britain and Switzerland.

Perhaps as interesting was that wait times for certain appointments were longest in cities overflowing with doctors. In Boston, for instance, it took 66 days to get a primary care appointment, and, in this mecca for heart care, 27 days to see a cardiologist.

The take home:

It all comes down to choices. In the non-magical world of healthcare, I see two choices for the non-CEO or doctor-patient.

If you want a humanistic experience with a doctor who will thoroughly explain the multiple paths of care, then support your decision, and then enact the chosen plan skillfully, you are likely going to wait.

If you or your referring doctor want immediate care, expect tradeoffs.

Tradeoffs are truth.

JMM

Comments

  1. says

    GREAT Post John. What you write is the truth (and one of the reasons I don’t miss seeing patients in primary care any more ….). I never liked “tradeoffs” …

    • pgyx says

      Yes, this is yet another sane, accurate, and eloquently written post by Dr. Mandrola.

      I just graduated from residency and am struggling with my distaste for tradeoffs. I was taught to thoroughly evaluate, treat, and educate patients during my medical education and training, but this approach (which my patients consistently praise) just does not seem sustainable in the current system. On the other hand, it is the only way I know how to do things so I am not sure there is a place for me.

      It seems many patients are unaware that checkbox medicine is mandated by government/insurance bureaucrats rather than by doctors. Both doctors and patients are losing as a result.

      • Lisa DeLille Bolton RN FNP says

        Dear Recent Resident,

        You have described my pain exactly. In a busy family practice and walk-in clinic, I received almost no clinical feedback from my preceptor in my two years as a brand new NP. What I did hear was: be faster, see more patients, chart later. NPs in my experience are no nicer and take no more time. We are under the same gun as MDs, and also frustrated with the difference between training and practice.

        The checkbox / faux copy-paste scenario is bad and wrong. Periodically I would review a one-page counsult note from a seasoned physician whom one of our patients had seen. It would be clear what the specialist recommended and why, and would be a pleasure to read.

        I am now in community outreach for a safety net hospital and feel I have found my place. You will find yours: med school was worth it. I remain confident that positive shifts are happening on multiple levels, as good sense catches up to profit-driven corporate madness (our current operating system.) Patients need patience, clearly.

        My hope is that doctors and nurses and other health care professionals (not to be confused with MBAs in suits) will team up and advocate for public policy change to promote greater sanity in our approach to both daily life (food, exercise, stress) and health care (not to be confused with health insurance).

        Kindest regards,
        Lisa DeLille Bolton RN FNP

  2. DoctorSH says

    DrJ

    Nice article and truthful!

    The issue is not your wait time.
    The issue is more that there are not enough trained primary care docs who can manage the early AF well enough that an urgent or quick visit to see you is not needed. A well managed primary can wait a few weeks or months.

    The problem with primary care is that in today’s system they are asked to see too many people in a day and when they can not spend the necessary time, they do what is easy, they refer.

    Get better trained primary care docs with time to manage their patients and your wait times will decrease.

    The causes of not enough primary care docs is not the topic of your post so I will give it a pass right now.

    • says

      Thanks SH. You are correct. When patients come from certain docs, it is much easier, for they come educated on the problem. Education of the patient lies at the core of good doctoring. But it takes the longest and pays the least. You already know that, though.

  3. Joe says

    It’s always curious when a guilded profession generates an entirely predictable shortage, and then goes on to observe that the self-inflicted shortage is making their professional life more difficult.

    Shortages mean that who you know and where you live become as or more important than the help you need. Those of us with family members working in the system know it’s true – we get better/faster/more friendly care because we know someone. Is that the system we want to perpetuate?

    Practitioners will continue to argue over how to split the $3.8 TRILLION health care spending pie, but patients continue to receive sub-par experiences considering the price paid.

    Collectively, we pay enough for first class service. Collectively, we receive first rate care in a few important areas and frustration that makes cable company service look desirable in most others.

    It’s a mess, and I appreciate those who continue to do their level best each day is a busted system. I wish the good guys were winning.

    • pgyx says

      But it’s not about shortages — in some cases, wait times are worse in areas with more doctors.

      The new “meaningful use” criteria for electronic medical records significantly add to the documentation time for each patient while subtracting from the quality of care and patient satisfaction. My institution recently switched to EMR — after a month of real-world use, most of the doctors are able to see only 50% of the patients we saw before the switch. And the resulting notes, despite tremendous effort & late work nights devoted to note-writing/clicking, are atrocious. I’m ashamed to sign my name to them, but they’re generated by a program I can’t re-code.

      In addition, physician salaries make up ~10% of healthcare spending. If you’d like to cut our salaries, would it be reasonable to subsidize medical education? Both med education & training delay physician earning (while debt & interest accrue) by several years compared to other fields.

    • says

      It is so very easy to become pessimistic. It is, as you eloquently say, a mess out there. And the nonsense is metastasizing. It seems every day brings a new farcical and distracting “regulation,” or form, or need for a signature. I think the gravest danger of all this is the extraction of joy from the care of others. I see it every day. People who do this important work seem less happy with it than they did in years past.

      But then there are elixirs–the patients with real problems whom you have helped, cured even, with electrophysiology techniques. These are the rewards that keep bringing you back to wrestle with the joy-extractors.

  4. Karl Wilcox says

    As a veteran competitive cyclist and a ‘Lone-A Fib’ sufferer, I have been less than impressed with my cardiologist’s willingness to discuss my athletic heart. The other day when I sat down to have a look with him at my EKG, stress test, etc., it became apparent to me that he was ‘sight-reading’ in terms of the diagnosis. I am not saying that the diagnosis was wrong, but I had to drag the information out of him. I felt like a college student again, trying to get a professor to explain my grade! Ironically, He kept confessing to me how he should exercise more but just can’t find the time, given the number of patients he has to see each day.

    The college analogy may be useful vis a vis John’s blog: I teach college English, and most of my students suffer from intellectual morbidity– they can barely read, they do not want to read, and they only care about getting a ‘pill’ that will keep them on the path to a diploma. Frankly, they don’t want a diagnosis– only a passing grade (preferably A or B). I suspect that my cardiologist has simply adapted to his ‘patients’ expectations and morbid conditions. Numbers are not the entire story, since the sheer level of illness in our society (entirely preventable in most cases) has led to a general disinclination to take one’s health seriously; like my students, survival values trump health goals! Illness and lots of meds are the new norm (rather like cheating on essay exams!).
    Cheers,
    Karl

  5. says

    As usual you present an interesting perspective. As a Canadian AF patient it takes three months, if I’m lucky, to see my primary care giver, and sometimes, when in his office waiting at least an hour more to be called, my consolation is that I know he’ll take at least an equal 30 minutes as he gave the last patient to discuss my situation. Bless the doctors that really doctor the mind, spirit and body.

    • says

      CM,

      One of my recently retired colleagues left a comment (on my Facebook wall where this post also ran) saying: “You probably don’t want to go to an AF doctor who can see you within 1 to 2 weeks.”
      He is right. A benefit of being a doctor is that I know who the best doctors are. When I have had the occasion to see them as a patient, I plan to wait; they all have very long waits. I bring something to read and find the wait a good time to disconnect from the world.

  6. Jay Schloss says

    Loved that piece. Gotta put a plug in, though for physician extenders.

    You and I know that the important stuff we do in the office (decision making, counseling, examination) take up only a fraction of the time required to “see” a patient. By employing a nurse practitioner, I can still give my patients all they need, and see them in a timely fashion (because many of the time consuming bureaucratic actions that patients don’t care about or notice get done by someone else). Since my NP sees patients at the same time as me, I can give everyone all the cognitive and face time they need and deserve, and still see new consults soon after they call for appointments.

    I’ve never used a scribe, but suspect this would also be really helpful if I could ever talk someone into paying for it.

  7. Verted says

    i guess I’m one of the lucky ones when it comes to a PCP. He practices in what used to be derisively called a “doc in a box” environment, where it’s walk in, but you can request a particular doctor if it’s for ongoing treatment. If it’s a routine medical issue, there are other docs, or physician assistants that can see you as well. I can also schedule a full physical appointment with my doctor.

    The staff handles triage of patients very well. Sure I’ve had some long waits to see my PCP, as it’s walk-in and triage, but once I’m seen, he spends all the time necessary with me – and more. There have only been a few times where he was SO busy that the wait would have been too long, and I would have to come back the following day. I’m constantly amazed at how well he juggles multiple patients, jumping from one cubicle to another while the nurses or PAs do blood work, Xrays, etc. Now, some patients may not like the multiple cubicle setting, and would prefer the traditional small exam room setting, but it does not bother me in the least.

    Did I mention he also has flex hours? All of the docs rotate with a posted schedule, so that I’m able to see my preferred doc or PA one day at 8AM, or perhaps on a Saturday at 9:30PM. I’ve even seen him on New Year’s day (and no, not for a hangover :-) ).

    This model may not work in the specialist environment, but it’s been great for PC with our family.

  8. Paul Caffrey says

    Another reason to take care of myself as much as possible. In todays world with the assistance of the web and the many forums, etc. available, it is much easier to do just that. Fact, I now know more about atrial fibrillation after nearly 5 years of suffering and learning about it, than probably most primary physicians. More emphasis on prevention and public health is definitely in order. This will likely lighten the load for doctors and reduce outrageous costs. Bring it on!