Itâ€™s time for another post on truth and healthcare. (This almost sounds like a good series.)
Iâ€™ve recently written that the VA healthcare system represents the truthâ€”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:
â€œReferring 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?â€
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, itâ€™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 â€œconnected,â€ letâ€™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 simpleâ€”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 doctorsâ€™ 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. Itâ€™s a pointless exercise because if the kid could be up there, she would. Itâ€™s the same with doctors. We really canâ€™t go any faster. Well, that is, if we donâ€™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, â€œtake this.â€
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 donâ€™t have the luxury of a nurse practitioner or physician assistant. Itâ€™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 patientâ€™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 approachâ€”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. Thatâ€™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. Itâ€™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.