I recently had an experience that opened my eyes to a big problem in medicine: availability. My son came to me one morning and said he was kept awake by the dripping over his bed. My roof was leaking. Once I found the source of the leak and discovered that it was more than I wanted to tackle, I needed to find a roofer. Every call to a roofing company resulted in a trip to their voicemail. I needed quick action, so I left messages with all the local companies, planning to use the first to respond. No one called me back. It turns out there is a shortage of roofers in my area, and they are backed up several months. They are so busy; they don’t even return calls in a timely manner. Return calls trickled in over the next few days, but some companies never returned my call. Those who finally responded couldn’t get to me for three to five months. What kind of service was that? My roof was leaking. In several months, who knows how much damage will occur. How could they run a business like that? During that same time, my wife needed an appointment with a specialist. When she called, they told her their next available opening was in two months. Two months! Don’t they understand she is having a problem now? How could they run a business like that? Physicians have fallen into the same work patterns as the rest of the world. If we are busy, patients will just have to wait. Is this really how we should behave in this noble profession? With lives and not just property at risk, I think we should respond better than roofers. Availability is one of the keys to great success as a physician. We have, in general, lost this attribute in our practices. Often, if an established patient calls their primary care doctor with an urgent problem, they are told to go to the emergency department or urgent care. What’s the point of having a primary care physician if they will not provide any primary care when it’s needed? That is not how it used to be. What has taken us to this state? Let’s look at four of the forces contributing to this problem. The first is the general physician shortage. Many years ago, Congress halted the expansion of medical schools and limited the number of physicians that could be produced each year. As the population grew, the number of physicians did not keep up, and today we have a physician shortage. Like my issue with the roofers, if the schedule is full, we don’t have a lot of interest in adding more work to our load. The second is the debt load physicians face. We face a huge burden to pay for our expensive training. We leave school with a home mortgage and no home. The debt is deferred for several years during residency and the interest compounds. When we start our practice, we add even more debt to the pile by buying houses, cars, and vacations. Many doctors find themselves a million dollars in the hole just a few years out of training. This high debt places a great demand on us to produce. Thus, we cram our schedule so full with the routine care patients, that there is no room for the urgent patients. The third issue is the physician employment movement. Employees do not have the same drive to produce as a business owner does. If we will not get paid more to add more to our schedule, we will often not do it. There is no incentive to see the urgent cases. In fact, there is a disincentive as the urgent patient will mess up our daily schedule. It has been shown time and again that an owner is generally more productive than an employee. When I performed surgery on a business owner, they wanted to be back to work on Monday. When I operated on an employee, they wanted to get as much time off as possible. There is a difference in production incentive when you eat what you kill. The final issue is quotas. When a physician is employed by a hospital, they demand high production, often in the form of quotas. When they impose quotas, we do not feel we can leave any space in the schedule for the urgent patients. What if nothing urgent comes in today, and I didn’t see as many patients as I could have? I might not meet my quota. If we’re not available, then the patient often ends up in the ED, which is a much more expensive and less effective way to provide health care. So what can we do? I always told my staff, if a patient calls with an urgent problem, don’t just tell them to go to the emergency department, let me in on the decision. We will determine if they truly need to go to the hospital or if I can handle it over the phone or see them in the office today. The ED doctor doesn’t know them or their problems, so they have to start from scratch. A good illustration is a patient of mine who went to the emergency department the morning after I took her gallbladder out as a locums surgeon. She was hurting. The ED physician did a CT scan and labs before bothering to call me. It turns out the patient didn’t take any of her pain medication. It was a normal post-op course. I could have solved the problem with a three-minute phone call. By seeing a doctor who did not know her or her case, she got a $2,000 work up that was not needed. Why did this happen? Because the patient had learned that, in her community, when she calls the doctor’s office, she is always referred to the ED for urgent care. Her doctor never works her into that day’s schedule. Also, if she did call the surgery office after hours, she was not put in touch with the on-call surgeon, she was told to go to the ED by a recorded message. The hospital, who owned the surgery practice, made more money after hours by sending the patient to the ED than by paying an answering service to contact her surgeon. We need to find a solution to the physician availability problem. The ED is not a primary care office, and they should not be doing patient follow-up. The emergency department is for emergencies. We need to find a way back to a system that will allow patients to see their own doctor in a timely fashion, not two months later. This is a very complex issue, but the debt portion can be eliminated. I made a choice many years ago to become debt free. Once my half-a-million dollar debt was eliminated, I had more options. I could book fewer patients in the office each day and leave room for the urgent ones. The day after my call weekend could be left open, so I would have room to handle all the emergencies I picked up. Since I didn’t feel the need for as much income to service my debt, my desire to push patients through like an assembly line was lessened. You can do the same. Let’s start eliminating the forces that keep our schedule overbooked and improve our availability to our patients. The physician shortage will not be improved for quite some time, but we could begin to make a difference with the things we can control. Our health care system will be a lot better when we can see our doctor when we need them. Each of us can do our part by changing the factors that are in our control. Patients will be very grateful. The system will run smoother. Health care will be better and more cost-effective. It’s a win-win deal. Let’s work together for a solution before some new government regulation tries to fix it for us. Source
