Getting an appointment with primary care is the Achilles’ heel of medicine [PODCAST]

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“‘Doctor, it’s taken so long to get this appointment with you!’ This is the opening line of so many medical visits, and I find myself constantly apologizing to my patients on behalf of our system. After the pandemic-induced lull in routine medical care, we’re right back where we started—doctors booked for months, patients struggling to get appointments.

The difficulty with access to medical care is endemic to our entire medical system. Even before the pandemic, less than a fifth of American doctors were able to take new patients, and more than 80 percent were at capacity or over-extended. Some 16,000 medical practices closed down because of the pandemic. This is especially concerning in primary care, which is on track for a shortage of up to 48,000 physicians. It’s not surprising that lack of access to primary care doctors is associated with higher mortality.”

Danielle Ofri is an internal medicine physician and editor-in-chief, Bellevue Literary Review, and is the author of When We Do Harm: A Doctor Confronts Medical Error.

She shares her story and discusses her KevinMD article, “Getting an appointment with primary care is the Achilles’ heel of medicine.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at KevinMD.com/rate. Subscribe at KevinMD.com/follow. Today we welcome back Danielle Ofri. She’s an internal medicine physician and editor-in-chief of the Bellevue Literary Review, and she’s the author of the book When We Do Harm: A Doctor Confronts Medical Error. Today we’re going to talk about her most recent KevinMD article titled “Getting an appointment with primary care is the Achilles’ heel of medicine.” That’s certainly something that I can relate to. I also do primary care internal medicine, and sometimes it does take eight to 10 months to get a physical appointment with me. So we’ll certainly talk more about that, but Danielle, welcome back to the show.

Danielle Ofri: Thank you, Kevin. So great to be back.

Kevin Pho: So we’ll get into the article a little bit, but for those who didn’t get a chance to listen to our first episode together, just briefly share your story and journey to where you are today.

Danielle Ofri: Sure. So I work at Bellevue Hospital, which is the oldest public hospital in the country, and I would probably qualify myself as a Bellevue lifer. I did my medical training there. I did my MD/PhD through NYU and Bellevue, and I did take off a year and a half after residency training to travel, did some locum tenens, and started writing. But then I came back to Bellevue because I just really love urban medicine, the chaos, which, the flip side, is really freedom, and I love the patients and colleagues. So I’ve been there now for a couple of years, and sort of on the side I began doing more writing.

And then we started the Bellevue Literary Review, because we thought maybe a creative writing outlet, poetry, fiction, and essays about health and healing, would be interesting. We just celebrated our 20th anniversary. We’re now an independent nonprofit literary arts organization. So I’m kind of balancing writing, editing, and of course seeing my patients, and monkeypox. I was just in the ER twice last night for some monkeypox cases. So if it’s not COVID, it’s monkeypox. Never a dull moment in primary care.

Kevin Pho: So as we all know, Bellevue is such an iconic medical institution in the United States, and you’ve been there for many, many years now. So tell me, what makes Bellevue so special as a primary care internal medicine physician?

Danielle Ofri: You know, it’s special because its doors are open to all. There’s no turning away anyone. I once had an experience in locum tenens in a private practice where I had to turn a patient away because they weren’t insured. I hadn’t realized that was the case, and I was told by the practice manager, “Oh, you can’t just bring these patients here.” I would call that the lowest moment of my life, telling a patient, “I cannot care for you because you can’t pay for it.” And I vowed then I’d never work in a place where I’d turn someone away for basic primary care.

So I do love the ethos. We take care of everyone, you know, from undocumented immigrants to presidents. We are the hospital in New York City for the president of the U.S., should they need hospital care or urgent care when they’re in New York. So we’re ready for all, including pandemics big and small. And it’s just the vitality. It’s just an incredibly diverse but also challenging place. We have lots of students and residents who are all attracted by the mission and really just want to do a great job. And so it’s just a really special place to be.

Kevin Pho: All right. I’m going to talk more about some of the challenges of primary care, and one of them is getting an appointment. We’re going to talk about that in your article titled “Getting an appointment with primary care is the Achilles’ heel of medicine.” Now, for those who didn’t get a chance to read your article, just walk my audience through it. Share the story of why you decided to write it.

Danielle Ofri: Well, really from both sides of the equation. Nearly every patient says to me, “Doc, it’s taking forever to get this appointment,” and, “I’ve waited so long in the waiting room.” Those are the two comments. Getting an appointment is really so hard. And then I had to get an appointment for my kid to get a pre-college physical. There was none to be had on the island of Manhattan, and we have a lot of doctors in New York City. To get into primary care as a new patient was months and months off. It was really a huge detective project for me to get my kid an appointment, and even then I couldn’t get an in-person one. I had to do a video visit first, just to earn a physical for a healthy kid.

And so it really woke me up to the issue. If we’re trying to improve health care outcomes, it really does start in primary care, because lack of primary care, as you well know, as most of us know, leads to such downstream cost, poor outcomes, and use of emergency care, which is a terribly expensive, inefficient, and really not a good way to take care of chronic medicine, which is really most of what medicine is these days. And so so much of what we want to accomplish in health care really lands in primary care, and yet you can’t get an appointment.

Kevin Pho: So this isn’t a new problem. I’ve been doing KevinMD for almost 20 years now, and the shortage of primary care clinicians has been an ongoing theme. So in your view, what are some of the root causes of why we cannot get appointments with primary care clinicians?

Danielle Ofri: There’s a couple of things. I mean, one is reimbursement levels. There’s no doubt that when you do primary care and spend the time educating your patient about exercise and diet, all the things that really work on treating chronic illnesses, that does not get a lot of reimbursement from insurance companies. So health systems, of course, want to focus on procedures, which make a lot of money. If you talk to a patient about eating broccoli, or brown rice instead of white rice, which will have a real impact on their diabetes, maybe your institution will get 45 bucks. But if, while you’re talking about kale and broccoli, you ran a CT scanner over them or put a tube into an orifice, the reimbursement goes up so much. So of course health systems really spend their energy and supplies and space and time on procedure-based specialties, which I don’t want to knock. They’re important, but we really give short shrift to primary care.

Then of course there are salary differentials. So for a lot of students with a huge pile of debt from medical school, I mean, why not go into ophthalmology and make twice as much? The hours are easier, less paperwork, less headache. So it’s really hard to get people to go into primary care.

Kevin Pho: So let’s talk about the cost of education that may influence medical students’ career choices. I know one solution at NYU, for instance: Medical school, I believe, is without cost now. So do you think that is a solution in terms of influencing more medical students to choose primary care as a career?

Danielle Ofri: Sure, but I thought that was a bit of a blunt instrument. I thought it could have been applied more selectively, to offer free tuition for those interested in primary care, rural medicine, inner-city medicine, geriatrics, things that really have a need. You don’t need free medical tuition if you’re going into plastic surgery. You really don’t. You can pay it back in six months. It’s not an issue. But for people going into primary care, or doing mission work overseas, that’s really hard to do, or public health, epidemiology. So I think we, or have some kind of sliding scale. Not that we want to force students to choose, but we could use those incentives, I think, differently. So that’s one thing.

I think the second thing that we can do is think a lot about what the primary care work life is like. Right now it’s a bit of a dumping ground. Every other specialty can say, “Oh, right, talk to your primary care doctor.” Every form, every issue can be dumped in primary care, and we of course can never say no. And so so much of our time is taken up with all kinds of non-clinical work, because our ambit is so wide, and we do more paperwork, I think, than most other fields. And so some attention to why are we doing this, and should all this be a primary care doctor’s responsibility, so that we can funnel more non-clinical resources to let primary care doctors just do primary care. If I didn’t have to spend so much time answering messages, and if I had more nurses, say, who could do some of that, I could see more patients. But right now it’s really hard to do the clinical work when you’re so laden down by other non-clinical issues.

Kevin Pho: So I’m sure you saw this study as well in the last couple weeks: If primary care doctors were to implement every single preventative care recommendation, it would take something like 27 hours a day, or something like that. So just to go to your point.

Danielle Ofri: Right. And so some of that could be done, for example, vaccinations. That’s really algorithmic. The EMR could pull that up. A nurse could do that. We don’t need to have a primary care doctor figure out who needs a Shingrix vaccine. I mean, maybe you could sign off on it, but it could be done in a way that takes a lot of this off primary care. We just instituted a new procedure at our hospital with FIT testing for colon cancer screening. Why don’t we just send a kit to every patient every year, and not have you waste three more neurons thinking about that at the expense of how do we control their hypertension? And lots of that could be done that way, so that it doesn’t just take up the primary care doc’s time. Because you’re right, it’s really impossible to do, and of course we reimburse so little for it, so our institutions don’t have money to hire a second clinical person or non-clinical person to take care of that aspect.

Kevin Pho: Now, you work with NYU medical students. So from their perspectives, what are their views of primary care? What kind of sense are you getting from the medical students that you interact with today?

Danielle Ofri: Well, I’ll say this: When they do their rotations in ambulatory care, they love it. It’s one of the best rotations, because it’s your first chance, honestly, to be a doctor. In primary care we generally let students be the doctor, and you suddenly get this window into the whole patient and not just this little narrow thing, and that’s really gratifying. You really feel like a doctor. So students really love it, but they also see how stressed their attendings are, how much is going on, how you’ve got to do 50 things at once. And you can see them, and they’ll say they are a little bit leery: “It feels good, but do I really want to do that?” So it takes a lot of inner drive to blast past the frustrating parts to key into the great parts of taking care of patients over years and seeing their families grow. But they are hesitant. They see how much baggage the primary care doctors hold.

Kevin Pho: Now, as fewer and fewer medical students choose primary care as a career, that leaves an opening for nurse practitioners and physician assistants to fill that gap. So we’re seeing more advanced practice providers go into primary care fields while physicians go to more specialty fields, and that’s the trend that’s been going on for the last few years and for the foreseeable future. What are your thoughts on that?

Danielle Ofri: I actually think it’s a great resource, because there’s lots of primary care that’s fairly straightforward and simple, and there’s some that’s really complex. And, you know, how do we define an internist, right? What is an internal medicine doctor? I think what we define ourselves on is complexity: Our patients with complex medical illnesses really do need an internist. They can’t be taken care of by 10 specialists. And so I think that’s really the role for internal medicine physicians.

And I welcome the advanced practice care clinicians. There’s so much of medicine that’s really very easily done and widely done with less training, so I think you can work well together. We have a great model in our clinic where we work together with PAs and NPs, and I think it works very well. But then there are some cases that absolutely need an internal medicine doctor to really put together the complexities of liver failure and renal failure and diabetes and hypertension and psychiatric issues that many of our patients, but not all, have.

Kevin Pho: So where do you see that trend leading to? Because as more advanced practice providers go into primary care, medical institutions are probably not going to pay physician salaries for primary care, and that’s going to further deter more medical students from going into primary care. So what do you think about that potential scenario?

Danielle Ofri: I think it will come down to the research showing outcomes, because we are interested in outcomes, and there is money on the table for outcomes. And so for complex cases, the outcomes are very difficult, I think, to manage without advanced-level training. If we’re looking, for example, at diabetes control, for simple patients it’s easy to get their glucose, their A1C, under 8. For complicated patients it’s very hard. And so institutions that are trying to do that will probably see, I think, poor outcomes if they get rid of all their primary care doctors.

So I think we can have a balance, and I really do enjoy the team approach, where one patient can have several practitioners as part of their team. Maybe they’ll see the PA or their NP for some of their visits, and they’ll see me for some of their visits, and that often works very well. And so I think we could make the case that it’s cost-effective and we can have good outcomes if we take advantage of the strengths of all the different team players: nutritionists, pharmacists. I mean, having a pharmacist on our team now, my patients can see me fewer times. That probably saves money, but they can get the good care they need if we can all work together. So I think we can make that case. We’ll just need our primary care health researchers to point that out.

Kevin Pho: We’re talking to Danielle Ofri. She’s an internal medicine physician, and she’s the author of the book When We Do Harm: A Doctor Confronts Medical Error. We’re talking about her latest KevinMD article titled “Getting an appointment with primary care is the Achilles’ heel of medicine.” So Danielle, what’s the path forward? I think a lot of the things that you brought up, like the pay disparity between proceduralists and primary care, have been going on for decades now. So is there anything more immediate in terms of what we can do to fill that primary care access gap?

Danielle Ofri: Well, again, cutting some of the non-clinical work we have to do and getting more support. But I think when we want to make the case to our institutions about why we need more time with primary care clinicians, I usually try to frame it around two things. One is patient safety, and one is patient satisfaction. Again, these are two metrics that people in suits care a lot about, because again, money is on the table for those things.

If you ask patients what makes them feel good about where they go, very few are going to mention, “Oh, the nice coffee machine, the graham crackers, the valet parking.” What they really enjoy is time with their doctor, and enough nurses in the clinic or on the wards. Those things really impact how patients feel. And so often we go for window dressing when it comes to trying to improve patient satisfaction scores. But ask any patient whether they’d rather have fancy coffee or a longer visit with their doctor. You know what they’ll choose. And so we can make that case.

And the second one is patient safety, which we care about a lot. We are trying to decrease medical errors, to decrease patient harm on all fronts. And having primary care doctors spend more time with their patients, there’s no doubt, I think, improves patient safety. Because the flip side is we spend fewer minutes with our patients and cut corners, and I can see it with my own patients. I know they’re not getting as good care. I’m sure I’m making mistakes. And so if I can have longer time with my patients, I can be really careful about medication reconciliation, checking their labs, all of those things. And so making that case in terms of patient satisfaction and patient safety, to the point of why we need more time with primary care and more access to primary care, I think is the quickest and short-term way to at least get the attention of those in decision-making roles.

Kevin Pho: We have a platform here where we have a lot of medical students and medical trainees listening to you. Why should they consider primary care as a career? And maybe you could end with some take-home messages.

Danielle Ofri: It’s the best field out there, I have to say. When a patient thinks about who is their doctor, they’re typically not mentioning their surgeon, their podiatrist, their ophthalmologist, even though they may like them, love them. But who is their doctor when they need counsel, advice, when they’re worried, when they feel sick? That’s their primary care doctor. And having that connection is so special, because when you think about how you move the needle for a patient, to make them come out of their experience feeling better physically, emotionally, spiritually, all of that, it really falls in the lap of primary care. We of course need and love our specialists to help with things that we can’t do, but the gratification, the gratitude of being in the primary care spot, there’s nothing like it.

I have a patient that I started taking care of when I was an intern, and I will not tell you how long ago that was, but he was discharged post-MI, NIDDM, and I picked up his chart. We’ve been together now. We’ve outlasted our friends’ marriages, remakes of the health care system, our clinic. We’ve done all that stuff, presidential administrations, and we’re still together. I’ve seen him raise his children, his grandchildren. You know, it’s so gratifying. And now we’re approaching this later stage in his life and thinking about advance care planning, and that I can be with him to think about end-of-life care as well is really special, because he really trusts me. I know him so well. He can walk in, and I know instantly when something is wrong. Even on the phone, I don’t need any blood test. I can tell. And having that kind of relationship, there’s really nothing like it.

Kevin Pho: Danielle, thank you so much for coming back on the show and sharing your time and insight.

Danielle Ofri: OK, thanks so much. Have a great day, everyone.

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