You have been losing weight. You feel weak and fatigued all the time. You’re not sure if you’ve simply been working too hard or have just been more stressed at work. You feel an occasional pain in your stomach and more heartburn than usual and, moreover, you have no appetite. You’re worried that it might be something more serious than simply stress and decide to call the doctor who asks if these are new symptoms or just chronic ones. You answer that you’re not sure and so you’re given an appointment three months in the future.
Now you’re not sure what to do. You’re not sure if it’s safe to wait that long. You consider calling the doctor back and saying that your symptoms have been much worse recently and you need an appointment much sooner. But you don’t want to seem to be calling wolf for no good reason. So what should you do?
This is one of the biggest problems in American medicine today. Access to a provider. There are many reasons for this as has been outlined in previous articles. But the real question is what can you do about it.
The first option is to see a mid-level provider: a nurse practitioner or a physician assistant. Many clinics utilize these folks because they know that their physicians are stretched beyond their capacity. They can be found populating urgent care centers, some pharmacies, emergency rooms and sometimes, depending on state guidelines, their own offices.
They can often be a fine gateway into the system and can sometimes give you the necessary initial advice that you are seeking. However they are not physicians. They are wonderful for routine matters and for providing good preventive health care advice. But if the diagnosis is potentially complex, like the example illustrated above, they will likely have to refer you on to someone else. That is if they recognize that it is a more complex problem. In most health care settings they have physician backup immediately but not in all settings.
Another option is to choose a concierge practice. Here, the primary care physician has chosen to limit the number of patients in his or her panel. In order to do this they charge an additional fee, on the order of fifteen hundred dollars a year, in addition to your usual health care premium. The advantage is that, for the fee, they agree to see you anytime that you feel it is necessary. The disadvantage is the cost. And the fact that as more primary care physicians choose this practice model, there are fewer physicians remaining to see everyone else.
At this point, it is estimated that only about twenty percent of medical students are choosing to go into primary care which further limits access to physician care as the present providers are retiring.
There are clinics available where patients aren’t assigned to any one physician provider and one of their providers will try to see you whenever you call. But they, like the urgent care centers, usually try to use a registered nurse or a mid-level provider to triage your problem. Although they often have specialty backup if the problem is too complex for the primary care physician. This model is often found in academic medical centers.
Some patients actually choose to make an appointment with a surgeon that they may have had a prior relationship with, or even with their chiropractor. But choosing someone without the requisite background in your problem may unnecessarily delay your diagnosis and treatment.
The bottom line is to assume that if your symptoms are not “normal” for you, if they deviate from what you are used to, there is something wrong and don’t delay being seen. Develop a timeline for the development of your symptoms. When did each symptom appear. Then be prepared, when you call for an appointment, to document their development and why you are concerned. And if you don’t have a primary care physician when the symptoms develop, go to an urgent care center, ideally one affiliated with the local hospital. They will be more likely to have access to specialists who can help as well.
Remember this problem of access is only likely to worsen over the next decade or more. And aligning yourself with a physician before you need one is always best.
But is this access problem insurmountable. Isn’t there something that can be done to improve things. I know at the beginning of this series I said that I was not planning on offering any solutions to the problems that exist. However in the next couple of articles I will discuss some possible directions that might be considered in redesigning the health care system to make it more responsive and less expensive than it currently is. It will not be easy. The current system is pretty firmly entrenched and the various stakeholders will be reluctant to changing the status quo. But it is not impossible. It just needs a little flexibility and a willingness to think outside the box.