Primary care today is like squeezing blood from a stone


In these strange days of unsure future health care policies, shrinking budgets, and significant belt-tightening, as we look for ways to improve access for our patients, we need to reevaluate how we to get them into care, making sure we see them in a timely and efficient manner.

We have always said that in this topsy-turvy time, in the crazy state of health care, what we really need is more primary care providers to take care of patients. If we build it, they will come. If we have more doctors trained as primary care providers, and give them enough space and a place to practice, and fill our schedules up with patients who need good primary care, it’s hard to imagine that we would not do a better job of getting our patients in, being more efficient, and improving the health of our patients and our nation in the long run.

Short of having those thousands of new primary care providers drop from the heavens, can we do more with what we’ve got?

Right now, providers are battered down with full panels, overbooked schedules, month-long waits for routine visits, and patients needing to prove that they are sick enough to deserve an exception to be seen earlier.

Where do we find more efficiencies? When I walk around our practice in the afternoon, most of the time it feels like there isn’t a square inch to spare.

More doctors and other providers, more hours, more space, more streamlined care, more technology — all may hold some keys to the solutions we need.

How do we get to those efficiencies? Do I want to double up doctors in the spaces we have, have providers assigned to see patients during every lunch hour, or fit patients into the imaginary brief sliver of time between two other pre-existing patient appointments?

Sure, when I get here at 7:30 in the morning, all of our exam rooms are lying there fallow, in a pristine state with crisp white paper stretched across the table tops, desktop computers sitting there humming waiting for order entry into the electronic health record, otoscopes and ophthalmoscopes hanging in their slots waiting for ears and eyes to look in, tongue depressors on the shelf waiting for tongues to depress.

But if you fill me up with patients then, when will I get to get the rest of the work done that I’m already doing during that time? If you say to me, why don’t you just work some more hours late into the evening, or weekends, doesn’t this just rob from Peter to pay Paul? The cost of having to have something change in one direction is that there is hardly any wiggle room left at the edges. If I open up my practice on weekends, true, my patients will have access, but I won’t have access to my family.

As we have looked at these problems, we have created a report to look at our efficiency of space utilization, seeing how many practitioners we have, how many exam rooms, doctors per session, patients per doctor, and are we optimizing what we have. Can we squeeze more doctors into this space, or more patients on the doctor’s schedule? Most of the time we are just busting at the seams.

Just today a new physician was added to our practice, and we are all looking for corners and shared space he can park himself in while he sees patients.

Extra office? Too-spacious exam room? Space to breathe? Not a chance.

When I have a patient I want to squeeze in on days I’m not in practice, I pretty much have to beg our medical technicians for a room, a little window of opportunity to get them into the exam room, just a quick pre-op, they need an EKG, just a quick listen to make sure this isn’t pneumonia, I promise I’ll get them out of there in 5 minutes.

The last thing in the world I want to do is make one of my partners who has a busy practice afternoon and is already running behind wait because I’m clogging up their exam room.

We can always schedule to the no-show rate, find areas where we are inefficient, note the days where we have fewer providers in practice and schedule to that, but that almost seems like a tiny glimmer, not a massive opportunity for growth, capacity, and access.

Squeezing blood from the stone, it feels like we’re more likely to make things worse than actually improve access, improve patient satisfaction, improve provider satisfaction, or improve care.

What would serve us best, and serve our patients best, would be to truly invest in primary care, double or quadruple our footprint in the health care landscape, and then we’ll take care of everything that needs taking care of. And then we can all breathe a little easier. With room to spare.

Fred N. Pelzman is an associate professor of medicine, New York Presbyterian Hospital and associate director, Weill Cornell Internal Medicine Associates, New York City, NY. He blogs at MedPage Today’s Building the Patient-Centered Medical Home.

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