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05:16 PM on 05/12/2011
I work in emergency departments and the number one waste of time and resources of the ER is dealing with patients who have poor primary care. So many cases could have been sent to the PCP the next day but the patient has no guidance from their primary. So many patients don't have primary care. And huge numbers of patients have chronic conditions that are poorly managed or not managed at all by a primary doctor and end up seeking expensive ER treatment for conditions that ER docs can't help. Good, numerous, and qualified primary care doctors are badly needed.
too often denied to speak
06:12 PM on 05/12/2011
As a Family Practice physician who now works in the ER, I can say you are mostly right- except many of these patients admit to being too lazy to make an appointment !
"It's easier just to come here !" is the comment I hear all the time. It's also why at 5 PM, we get a large rush of patients, almost always on Medicaid, for minor things they should see their doctor for, but don't want to take time off from work to do so .
If the Hospital Administrators would grow a backbone and let us refuse to treat nonemegencies, a lot of this problem would correct itself.
07:30 PM on 05/12/2011
I am a primary care physician. I am board certified in Internal Medicine and enjoy the challange of the mix of intellectual(science-fact based medicine) and art( eccentricities of each patient) that goes into primary care. The trust of the patient is indispensible. The importance of this trust is something I don't think anyone really understands unless you experience it yourself. One has to actually practice medicine to understand what I'm saying. That's a problem. All our experts are perhaps "book" smart but they are about to really mess things up. The old time "family doctor" that many of us in our 50's and 60's grew up with is being abolished. You will not know your doctors in the new medicine(Obamacare) and the doctor will not see you as an individual but as a disease that is given a score that determines how much on average the doctor can spend of the govts. money to treat you. Say you need to be hospitalized for a appendectomy....well the govt. statistics will predict the average case should take 4 hospital days and X amt. of $$ for tests like blood work and otherthings....if you heal slow or costs more...instead of the medical team feeling extra sympathy they get a bit ticked off since you will make them look bad...not cost efficient.All patient-doctor interactions will be distorted. The expensive patients will be the new "lepers" one wants them.
03:39 AM on 05/13/2011
Everything you said about health care reform legislation is completely false. You are not a scientist, but an ideologue.
Humanity above Profit
08:57 AM on 05/13/2011
We already had that paradigmn, it was known as HMO's and we rejected it as it did not serve our needs. "Obamacare" as you call it is the beginning, not the finished product of health care for the American future. Our present system sucks and is going nowhere.
For-profit medicine sucks. We need to take a hint from the rest of the industrialized world about health carre and make some drastic changes, but first we have to rein in big insurance, big pharma, etc. or we will get nowhere.
I am a volunteer, Tong Ren distant energy healer.
04:59 PM on 05/12/2011
I think that healthcare will definitely change because of demographics.
Our current system developed while young healthy Baby Boomers were paying into the the system and not draining it. So the system was driven by profits, resulting in inefficiency. This inefficiency has forced the changes over the past 20 years to HMOs and limited coverage.
I think that healthcare needs to be affordable to avoid a breakdown, so profits need to be limited.
Countries that provide public healthcare have all limited the reimbursements paid for drugs. Doctors and patients have also had to make concessions.
I don't think we can afford to have doctors spending time talking to patients about life style health issues. This is being done now by counselors and other public information resources. Patients have to take more responsibility for their life style choices.
Lastly, I think that subtle energy will continue to play an increasing role in healthcare. This is exemplified by the breakdown of modern psychology into little more than drug maintenance programs. What is emerging from practice and current studies is the value of meditation, which is now being taught in psychology schools. Meditation can do a great deal for stress management and the control of related health issues.
I think that the value of subtle energy practices will continue to become more apparent to all because they will empower people with greater control over their own health.
The Truth will out
01:37 PM on 05/12/2011
Dr. Haines:
I respect greatly your reasons for entering FP, but I vigorously dispute your view of "primary care physicians - aren't pediatricians "primary care" docs for kids? Moreover, Dr. Haines, I would also submit that, based on the training requirements for FP certification, a parent borders on incompetent by bringing a child to a FP doc if given the option to go to a pediatrician. Having at most 2 months of pediatric experience in a 3 year training program(as opposed to 3 years in a peditric program) is hardly equivalent. No doubt, in the days when Old Doc Jones was all things to all people in a community, that was as good as it got, but then in those days, Doc Jones did not have to know as much as a physician does today.

What the politicos in and out of the medical community want is a breed of MD's who, like robots, follow "rules of practice" which may be fine at their inception, but like all else, will eventually become graven in stone and substitute for cerebration - easier this way to govern medical practice than to change regulations for certiification, which took 150 years to achieve in this country. Insurance companies are governed by the profit rule; labor is their highest cost, so the more primary care docs produced, the easier to drive down the cost of that labor. If you doubt my reasoning, just check in with Governor Walker. Dr. Welby never existed, Dorothy.
12:54 PM on 05/12/2011
It is not gone forever in other countries but then you would have to move. We will be retiring in another country and one of the reasons is the medical care. We will not have to worry that in the future we will have to make the decision to either die or lose our home. I know this is not the doctors fault (my son is a doctor) but the system.
In the country we will move to upon retirement one of the differences mentioned was seeing a doctor. They said prepare to take your time because the doctor will spend 30 or 45 minutes with you talking about your lifestye. It sounded like the doctor visits of 50 year ago and I am looking forward to it!!

So, no, primary care, as your dad and Grandpa T knew it, is not gone forever. It just doesn't exist in the US where insurance, drug companies, and hospitals run (or is that ruin) the medical care.
11:46 AM on 05/12/2011
My husband is an internist, who has been practicing for 40 years, so we have lived through the changes. Dr. Haines is exactly right. The internist/patient relationship is ongoing over the years, and this continuity is not only beneficial for the patient, but more efficient for the system. When a doctor knows his patients well, he can treat minor things on the phone; he can see the patient at night or on a week end instead of sending him to an ER. He doesn't have to test extensively, in some instances, because, knowing the patients' history, he knows how to deal with the problem. The internist is also the patient's advocate, and can coordinate fragmented specialists' care. The problem is that most young doctors want to make more money, and have less call. They join large groups, and are told how many patients they must see each day. More impersonal, less cost efficient, and much less kind. For those of us who have known the best care - it's very sad. And FP's and NP's simply do not have the experience or knowledge base to do the job of doctors. They are not interchangeable.
The Truth will out
01:46 PM on 05/12/2011
Do you recall the recent post regarding the 80 hour work week? What you describe as the "young doctors" are, in large measure, the products of this. I recall interviewing an intern candidate whom I told, "when I was at your stage, an 80 hour professional work week seemed like Nirvana while working >105 hours a week; what is your concept of Nirvana"? His reply? "Fourty hours a week"!!!! In a nutshell, that is the problem. I have classmates, looking to retire, who cannot hire replacements because they want more money than my colleagues are making after 30 years, right from the start. In addition, in order to cover the practice as before, it often will require another half time position or more, because the "young doctor" won't work such long hours. Net result? Increased cost of health care from morphing one doctor into two and paying both more than the first! How's that for economic reality, ACGME????!!!!
03:43 AM on 05/13/2011
So you would rather brutally exploit the cheap labor of residents and then have them make potentially fatal mistakes when working with their patients?
I'll burn that bridge when I come to it.
11:31 AM on 05/12/2011
Two of the reasons primary care is declining, 1 is co-pays, the other is the premium placed on specialists.

Specialist premiums are pretty self explanitory, become a specialist get factors more money.

Co-pays and beductibles are a huge barrier to obtaining care. You pay your $20 and go to the doctor, a follow up is another $20, if you forgot something its another $20. and on it goes. Since no co-pay single payer seems to be off the table here in the U.S., business and government leaders have to come up with a capitalistic way of eleminating these fees, which are a barrier and are nickling and diming patients to death.

Coming up with an all inclusive pay structure which puts primary care as the co-ordinator of health care will not only stop the parisitic drain on patients bank accounts, but will result in better health outcomes as well. And will highlight the importance of the primary care provider.

BUT, the health care industry has to buy in and accept changes. Are you ready for that?
The Truth will out
01:51 PM on 05/12/2011
You forgot about the NO-PAYS! People would never expect a plumber to come at 3 a.m. to fix a leak and leave the premises without his bill paid. How many patients expect to do that at their doctors' offices and then seek insurance reimbursement? Many simply ignore the bills, perhaps out of hardship, I agree, but there are others who are simply stiffing the doc. Add to this, the insurance company NO-PAYS and you've pretty much got the picture. Specialists don't see this as much, which helps to explain their higher income, but there are clearly other reasons, as well.
05:21 PM on 05/12/2011
co-pays are there to discourage unwarranted over utilization... You can't have people running to the doctor every time they get a tummy ache, however, I agree that co-pays for follow-ups, etc... are parasitic!
too often denied to speak
06:16 PM on 05/12/2011
We need copays on Medicaid !
You just described most of the patients on it. I've personally seen 3 people in the ER who already have over 30 visits this year- all for nonemergencies. And ALL were on Medicaid, which is totally free to them.