A guest column by the American College of Physicians, exclusive to KevinMD.com.
Lately, I’ve been asking myself whether today’s patient is less able to self-manage minor illnesses than their parents or grandparents. That question was inspired by my review of notes from my patients’ visits with my nurse practitioners or to our after-hours clinic, as well as some of my own patient encounters.
My practice has done a great job of providing access to office visits during regular and off-hours. Our enhanced access has reduced the number of visits to hospital emergency departments and freestanding urgent care centers. It has also increased patient satisfaction – they love the convenience and the integration with their primary care office.
What I am seeing is that many of these visits are by healthy young and middle aged people for minor illnesses such as head colds. These are conditions for which we have little more to offer than what is available in the “Cold Remedies” aisle of the pharmacy.
Do these types of office visits bother physicians? It depends on whom you ask. Over the years, I’ve discussed the case mix of a typical office day with colleagues, and heard mixed opinions. Some don’t mind seeing patients with “easy” problems because they can be a welcome break from more intense visits. I have to confess that I’ve felt that way on occasion.
Another theoretical benefit of these visits is that they provide a primary care physician with an opportunity to make sure the patient, who might not otherwise visit the office regularly, is up to date with preventive services. Financially, these visits may be advantageous because of the higher payment relative to the work required.
On the other hand, I’ve heard other physicians say that they would prefer to see the sicker, more complex patients for which their training prepared them and have other providers, such as advanced care practitioners or retail clinics, see the patients with sore throats and colds.
In researching the subject for this column, I didn’t find many relevant references that described this phenomenon, although I found it interesting that this has been a topic of concern in England and Canada for years, probably because of universal health care.
Anecdotally, I’ve cared for patients who came in for a head cold only because they had to get a doctor’s note for their work absence. Others were pressured by family members or friends to see the doctor. A few believed that an office visit would increase their odds of getting a coveted antibiotic prescription. Some truly did not understand that their illness would resolve on its own or were not sure about what they could take for the symptoms.
With respect to that last reason, I have to wonder whether this reflects shortcomings in our educational system, or even parenting. I reviewed the health curriculum for the Rhode Island Department of Education and found a standard of evaluate all factors that influence personal selection of health products and services in the community designed to prevent and/or control disease. (Required topics: health and safety products; OTC treatments for disease symptoms; selection of health care providers).
Does that include teaching how to manage a head cold? I don’t know.
Does increased access invite people to go to the doctor when they could take care of themselves? In other words, does making it easier to see the doctor increase demand? Sometimes I wonder.
Are trends in drug advertising an unexpected contributor? When I was a kid, only over-the-counter medications could be advertised, so I knew what to take for a stuffy nose, a stomach ache, or “irregularity” from what I saw on television. Today’s drug commercials educate people on which anticoagulant they can take for atrial fibrillation or how to treat chemotherapy-related fatigue, but not how to treat a cold.
What’s the harm from all of this? First, although it is preferable that patients with simple upper respiratory infections stay away from more expensive sites of service such as emergency departments and urgent care centers, a regular office visit still costs more than staying home does. While an office visit is cheaper than an emergency department visit, according to the 2013 National Ambulatory Medical Care Survey, there were over 24 million office visits for “Acute upper respiratory infections, excluding pharyngitis,” so it still adds up to a large expenditure.
I am also concerned that beyond the cost of the visit to the patient and insurer, going to the office increases the likelihood of testing, some of it inappropriate, and of medications being prescribed, including antibiotics.
Before ACP starts receiving angry e-mails and tweets, let me be clear — I am not referring to patients with chronic conditions for whom a viral respiratory illness can be a life-threatening event. Nor am I advocating for limiting people’s access based on acuity of illness.
It seems to me that, just as we devote resources to helping patients manage their chronic diseases, we should be educating them on self-management of common minor conditions. My practice offers educational programs for patients with diabetes or COPD — should we start doing the same for managing common acute conditions? Are we taking full advantage of our patient portals by providing links to high-quality patient education materials, such as the American College of Physicians’ collection, which includes a nice booklet on upper respiratory infections?
As we do more to increase patient engagement and empowerment, let’s not forget these relatively minor conditions, which affect almost all of our patients.
Yul Ejnes is an internal medicine physician and a past chair, board of regents, American College of Physicians. His statements do not necessarily reflect official policies of ACP.
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