Long waits to access primary care are avoidable

“Cheers!” “To good health,” my girlfriend and I toasted in the living room of our apartment joined by my parents on speakerphone.

It had been 12 years since my last radiation treatment—my last treatment for Hodgkin’s Lymphoma. Tonight was the anniversary of my remission, and in the case of Hodgkin’s—a cancer with an exceedingly low relapse rate—tonight was my anniversary of being cured.

I kissed my girlfriend goodbye and tread the dark sidewalk to the hospital. Tonight, like every night for the past four nights, I would be working the admitting night intern shift: running up and down the stairwell of this massive hospital admitting patients who arrive to the emergency room. And in a few short hours, I would admit Ms. P for expedited work-up of her diffuse swollen lymph nodes.

I was 15 when I was diagnosed with Hodgkin’s Lymphoma. I was at summer camp in New Hampshire—spending my days kicking soccer balls, hiking nearby peaks of the White Mountains, and being carefree. For weeks, I noticed a growing lump over my right collarbone; it didn’t bother me much, but it wasn’t going away.

Ms. P will be 41 years old when she is diagnosed with Hodgkin’s Lymphoma. She has two young children, ages 7 and 9. She is a full-time mom, probably the furthest thing from being carefree. For weeks, she too noticed growing lumps—over her right collarbone and in her right armpit, that weren’t going away.

At summer camp, the health care system allowed only one way to access care: the camp nurse. I walked the pine needle-blanketed path to the infirmary during the break before lunch. After dinner, that same day, I was evaluated by the camp doctor and sent to the local emergency room for tests. A chest x-ray showed signs of lymphoma. Four days later, back home in Cleveland, after a biopsy that removed the lump, I woke up with an oncologist at my bedside who broke the news that I had Hodgkin’s Lymphoma.

The system failed Ms. P. In October, when she realized her lumps were not going away—just as I had realized 12 years earlier—she called for an appointment with her primary care physician. However, unlike the summer camp health care system that allowed me same-day access, Ms. P’s primary care clinic gave her the next available slot: in December, two months later.

At her appointment, Ms. P’s primary care physician examined her and found swollen lymph nodes in her neck, groin, and both armpits. She was sent for a CT scan of her chest, abdomen, and pelvis. The impression read: “lymphoma, biopsy needed to confirm.” Maybe because of the two months of lag time, swollen lymph nodes were noted above and below the diaphragm, as opposed to just on one side like mine, worsening Ms. P’s chances of recovering. A biopsy was scheduled and performed, but the sample was inadequate for processing. Anxious at having not heard the results of her biopsy, she drove herself to the emergency room.

Now midnight, I was in the ED listening to Ms. P’s story. I couldn’t believe the parallels between mine and Ms. P’s stories, and on this of all nights. But I was also frustrated: How did she end up waiting two months for an appointment, while I was able to see a nurse the same day I attempted to access care?

In the early 1990’s, a physician named Mark Murray was charged by his organization with answering this question. His job was to figure out how to reduce wait times for primary care appointments. To accomplish this, his team created a new access model—advanced access—in which the one rule was “do today’s work today.” Patients calling for any problem, whether routine, urgent, or preventive, would see their personal provider that same day. In less than a year, the new access system reduced their primary care appointment wait time from 55 days to one. While only dozens of practices and organizations have successfully implemented advanced access, they have varied in size, payment structure, and patient demographics. Advanced access is challenging to achieve, but it is possible in practices that have every member of the primary care team working at the top of his or her license.

Ms. P’s wait time for an appointment was not due to inequality: she had both health insurance and a primary care doctor. Nor was it an inevitable side effect of the worsening primary care physician shortage: demand does not exceed supply if wait time is constant. That is, if Ms. P had called one month earlier for an appointment, her wait time still would have been two months, just as it would if she had called one month later. This was a patient safety event: the process by which Ms. P’s primary care practice schedules appointments caused unintended harm. Had her practice implemented advanced access, her hospitalization for expedited work-up could have been avoided and her chemotherapy could have begun sooner and maybe for a shorter duration.

I have visited five practices that have implemented advanced access, from an Alaska Native health system in Anchorage to a residency clinic in Pawtucket, Rhode Island. Since meeting Ms. P, I plan to visit many more. During my residency, visiting and talking about these practices may be the extent of what I am able to accomplish. However, looking forward, I plan to devote my career to primary care innovation. Long waits to access primary care are as avoidable and hazardous as central line infections and medication errors.  Just as the inpatient safety movement necessitates a new culture in the hospital, implementing advanced access requires a paradigm shift in clinics to encompass every member of the primary care team all the way to the trainee.

David Margolius is a primary care resident who blogs at Primary Care Progress.

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