Docs on DemandMarina Krakovsky talks with readers about same-day access to physicians.
Posted Thursday, Sept. 6, 2007, at 6:18 PM ETMarina Krakovsky was online at Washingtonpost.com on Thursday, Sept. 6, to discuss doctors' offices where patients don't wait long to be seen. An unedited transcript of the chat follows.
When my child has an accident or is ill, I first contact PAMF's advice nurse, who helps determine whether or not his condition warrants being seen by the clinic. If so, the nurse transfers me to the scheduling desk and a same-day appointment is made. If, during that visit, his doctor feels he needs more immediate attention that cannot sufficiently be addressed or handled by the facility, my son is directly transferred to the ER for further care. PAMF's open access is providing quality care to its patients while assisting in decreasing unnecessary and unwarranted visits to the ER.
Marina Krakovsky: Hello, neighbor! Yes, I've heard wonderful things about PAMF. And they weren't always like this, not by a long shot. So that's another testament to the possibility of change that I hope will be an inspiration to others.
_______________________
Alexandria, Va.: As a "sicker adult," the ability to make an appointment on the same day has been a need for me for several years. I am lucky to have an internist who usually can accomodate me, but I have two specialists who enlist a phone tree answering system that makes it virtually impossible to even speak to someone in a day or two, let alone make an appointment—taht usually takes two to three weeks. Especially annoying is the warning that the recorded system provides, saying that "if this is an emergency, hang up and dial 911." It's as if they are preempting any attempt at obtaining an appointment quickly. I'd like to think that this new system you describe would be the future of medicine, but I fear that my experiences suggest that it only will become worse.
Marina Krakovsky: I'm optimistic, and hope that by continuing this discussion, we can help the open-access movement along.
_______________________
Marina Krakovsky: Thank you all for participating, and I'm sorry we didn't have time for all the questions. Best wishes on speedy access!
Marina Krakovsky writes mainly about ideas in science, culture, and business. Her work has appeared in Discover
, the New York Times Magazine
, Psychology Today
, and the Washington Post
. Remarks from the Fray:
Most of the discussion was about acute/subacute visits and ignores huge primary care responsibilities. It sets up a system where the backlog is almost always large. You have to schedule ahead -- for convenience and malpractice issues you can't just tell someone to do it themselves. With health maintenance and follow-up visits for hundreds or thousands of patients most of the day is full. After that it's MD preference. I have worked with doctors who refuse to schedule a patient after 2PM (to do follow-up, calls, paperwork, and finish up the visits from the morning) and doctors who stay as long as is needed until every "I need to see a doctor today" visit is done. I like (and follow the example of) the latter.
Yes, it's difficult with insurance limits and the wait for a "new patient" appointment slot, but trying to find a doctor who will always see you within a day is worth it. Many exist, but MD's (outside of the few trolling for cash-paying botox visits) still resist advertising shorter wait times, so it's frustrating to wait 2-4 months to see a new MD just to find more of the same lack of responsiveness. It's just the bias of training to not appear to look for business -- maybe that would put a competitive pressure on other MD's if they saw their patients moving away to better, more responsive MD's.
Also, amongst the biggest reasons for a wait is simple supply and demand -- subspecialists limit their numbers severely by only training a set number per year (and subspecialty licensing generally requires going through an official training program, as does getting hospital privileges for most better quality hospitals).
--coutneyandphoney
(To reply, click here.)
What we do in medical care is triage. We assess who needs attention more than others. So to mention triage as though it's burdensome is not really relevant. Then to go on to say that the Palo Alto Medical Foundation works well because of a system that is exactly triage, shows a lack of understanding of the dynamics of medical care. Just because someone believes he/she has a condition that warrants immediate treatment does not mean that's the case. Sorry. We're used to immediate attention in the U.S. and that's one of the reasons we have these complaints.
Doc in the boxes can keep a more regular schedule because they aren't anyone's primary care provider, or at least they aren't supposed to be. So they don't end up having the sometimes long conversations that can occur at visits about people's lives. They also don't usually perform physicals or other potentially lengthy counseling visits unless they are contracted to do so.
What this article could have been about is the way the medical system can use all of its staff to provide better care. Sometimes counseling can be done by a nurse, or a nutritionist, or other staff, and doesn't have to be done by a physician. But a practice needs to be reimbursed for that time and not just for the doctor's time. It may be that the doctor, believe it or not, is not the most knowledgeable source about things like all of the possible birth control options, and a health educator would do better. These alternative staffing options are what needs to be discussed to get people the right care they need for their own particular issues. Then time is saved care needs. But then patients need to recognize that the doctor is not always the one who will be advising you and that needs to be OK.
--sundance22
(To reply, click here.)
(9/13)
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Remarks from the Fray:
Most of the discussion was about acute/subacute visits and ignores huge primary care responsibilities. It sets up a system where the backlog is almost always large. You have to schedule ahead -- for convenience and malpractice issues you can't just tell someone to do it themselves. With health maintenance and follow-up visits for hundreds or thousands of patients most of the day is full. After that it's MD preference. I have worked with doctors who refuse to schedule a patient after 2PM (to do follow-up, calls, paperwork, and finish up the visits from the morning) and doctors who stay as long as is needed until every "I need to see a doctor today" visit is done. I like (and follow the example of) the latter.
Yes, it's difficult with insurance limits and the wait for a "new patient" appointment slot, but trying to find a doctor who will always see you within a day is worth it. Many exist, but MD's (outside of the few trolling for cash-paying botox visits) still resist advertising shorter wait times, so it's frustrating to wait 2-4 months to see a new MD just to find more of the same lack of responsiveness. It's just the bias of training to not appear to look for business -- maybe that would put a competitive pressure on other MD's if they saw their patients moving away to better, more responsive MD's.
Also, amongst the biggest reasons for a wait is simple supply and demand -- subspecialists limit their numbers severely by only training a set number per year (and subspecialty licensing generally requires going through an official training program, as does getting hospital privileges for most better quality hospitals).
--coutneyandphoney
(To reply, click here.)
What we do in medical care is triage. We assess who needs attention more than others. So to mention triage as though it's burdensome is not really relevant. Then to go on to say that the Palo Alto Medical Foundation works well because of a system that is exactly triage, shows a lack of understanding of the dynamics of medical care. Just because someone believes he/she has a condition that warrants immediate treatment does not mean that's the case. Sorry. We're used to immediate attention in the U.S. and that's one of the reasons we have these complaints.
Doc in the boxes can keep a more regular schedule because they aren't anyone's primary care provider, or at least they aren't supposed to be. So they don't end up having the sometimes long conversations that can occur at visits about people's lives. They also don't usually perform physicals or other potentially lengthy counseling visits unless they are contracted to do so.
What this article could have been about is the way the medical system can use all of its staff to provide better care. Sometimes counseling can be done by a nurse, or a nutritionist, or other staff, and doesn't have to be done by a physician. But a practice needs to be reimbursed for that time and not just for the doctor's time. It may be that the doctor, believe it or not, is not the most knowledgeable source about things like all of the possible birth control options, and a health educator would do better. These alternative staffing options are what needs to be discussed to get people the right care they need for their own particular issues. Then time is saved care needs. But then patients need to recognize that the doctor is not always the one who will be advising you and that needs to be OK.
--sundance22
(To reply, click here.)
(9/13)