Recently, a patient I have known for several years called my office and spoke to my nurse. She said that while she was driving, her vision had gone blank for one second and then she was fine. My schedule was already overbooked. Almost all of the slots were filled with patients with the usual array of multiple chronic medical problems for follow-up and management of what were, for the most part, stable conditions.
Thus my nurse sent her to urgent care, a unit set up so that patients can see a health care provider quickly for acute medical problems rather than go to the emergency room. The necessity for such a system has developed gradually as the burden of prevention, chronic care, documentation, and paperwork has eroded the flexibility of many internists to squeeze in the extra patient with an acute problem. The result, paradoxically, is that I see my patients when they are well or stable, and urgent care sees them when they are sick — the reverse of what should happen. The cost of such a system can be significant, as this story illustrates.
The nurse practitioner who saw my patient in urgent care sent her to the emergency room for evaluation for what’s called, in layman’s terms, a “mini-stroke,” also known as a transient ischemic attack or TIA. Once in the emergency room, my patient was seen by the medical service and then the neurology service who, not surprisingly, ordered MRIs that were entirely normal. After several hours, the clinic sent her home with instructions to follow up with her primary care physician.
I saw her a few days later and carefully reviewed her history which confirmed the story of a 1-2 second bilateral white-out of her entire visual field, which resolved with complete visual clarity in the time it took to blink. She had no preceding symptoms: no heart palpitations, no lightheadedness, no other focal neurological symptoms. Except for a burst of anxiety, she felt entirely well after the episode and has remained so.
I thought about the close to $10,000 that was spent ruling out a serious cause of her symptoms. If I had been able to see her, would it have made a difference in her management? I believe it would have for two reasons. After listening to her story in detail, I was confident this was not a significant neurologic event. Because she knows and trusts me, I was able to reassure her with my opinion, which interestingly the normal scans had not been able to accomplish. But equally importantly, because I knew her well, I was willing to take responsibility for my decision. One of the hallmarks of being a primary care physician is to be comfortable with uncertainty. We learn to trust our clinical judgment and not jump to ordering expensive tests “just to be sure.” It is hard to accept responsibility for such decisions when the patient is unknown to you.
It is clear that we need to redesign primary care so that we can see our patients when they are sick, not just when they are well. The patient-centered medical home is one model that might allow for that, and there are undoubtedly others, but whatever the design, we cannot assume that medical personnel are interchangeable. The knowledge that a health care provider gains about a patient over years coupled with the trust that such a relationship builds for both the doctor and the patient are essential components of cost-effective medical care.
Katharine Treadway is an internal medicine physician who blogs at Primary Care Progress.
