How the primary care shortage affects the ER

Bill M. is a 22-year old college student who has had asthma and diabetes since he was a child. He comes in with trouble breathing because he has no primary care doctor and is out of his inhalers. While he’s in the ER, he also says that his diabetes hasn’t been followed for years, and now his blood sugars are out of control and he has new problems with his kidneys and his eyes.

Rani K. is a 46-year old who moved from India to take a research position. She has had dark stools for a month, and now feels intermittently lightheaded. Her blood counts are borderline low. She needs an endoscopy and further testing—tests that can be done as an outpatient, but she gets admitted because she has no primary care doctor and the wait for to see a new one is 103 days.

Annie K. is a 35-year mother of three who has an infection in her leg that will probably get better with antibiotics, but will need to get checked by a practitioner in two days. Her doctor does not have an appointment for a month, so she is told to come back to the ER for a wound check. Even with insurance, each ER visit will cost her $250.

I am an emergency physician. These are real stories of patients I see in the ER. Patients like Bill come in with severe complications of problems that can be prevented or managed—if they had a primary care doctor to follow-up with. Patients like Rani who get admitted to the hospital or like Annie who get told to return because they need urgent follow-up—but have no primary care doctor available to them.

The dearth of primary care physicians is a serious problem facing the U.S. healthcare system. The deficit for doctors is astounding, with a predicted shortage of 100,000 physicians by 2020. This shortage is particularly acute in primary care fields and in underserved areas. The reasons are multifactorial, and have to do with historical policies limiting physician workforce as well as ongoing problems with reimbursement, lifestyle, and service inclination.

We emergency physicians will always treat all-comers to our ERs to the best of our abilities. Emergency physicians are a creative bunch, and already, we have created value in areas of greatest need, for example, with pioneering observation medicine units and starting urgent-care follow-up clinics. Still, we as a society need to recognize that to deliver really excellent medical care, we must ensure a robust primary care system, and take steps to strengthen our existing primary care infrastructure through coordinating and task-shifting medical care, reconsidering payment and incentives, and realigning medical education with societal need. Primary care is the backbone of our society, and here in the ER, we see why it is so urgently needed, every single day.

Leana Wen is an emergency physician who blogs at The Doctor is Listening. She is the co-author of When Doctors Don’t Listen: How to Prevent Misdiagnosis and Unnecessary Tests.  She can also be reached on Twitter @drleanawen.

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