Attention seniors: The Hospital is not a Holiday Inn.

[VA Hopeful Dr]

Going to be regional. Maybe in a rural rural area you can slide in next week.

In my area it’s about 3-4 months for neuro or GI. 3 months for any actual psychiatrist that’s not some fake nurse. We seem real saturated on cards. Can get an appointment in 2-3 weeks but they still do useless stress testing and stress is booked out 3-4 months. Some are using ccta but that’s even worse.

Once I moved here I tried to find a pcp. The top 5 recommended to me are 3-5 months for a new patient unless I wanted to see the mid level.

@VA Hopeful Dr can speak more accurately

Definitely regional. And FWIW the person you're responding to lives in Australia.

I'm booked out 3 months for new patients at the moment. We don't book out any more than that due to the high no show rate if we do. My internist wife is booked out 7 months at the moment. That said, once you're a patient you can get an appointment with me within 2-3 days at the most. Can usually do same day/next day if you call in the early morning.

---

Members don't see this ad.

 

[Vandalia]

Just out of curiosity, I decided to go to the patient portal and check with my physician: A family med physician in the midwest. City of about 100K.

One "problem visit" slot available in a week at 7:15 am. The next open appointment - problem not routine - is three weeks away. Again, one appointment slot. Starting 5 weeks out there are multiple vacancies in a day.

 

[VA Hopeful Dr]

Just out of curiosity, I decided to go to the patient portal and check with my physician: A family med physician in the midwest. City of about 100K.

One "problem visit" slot available in a week at 7:15 am. The next open appointment - problem not routine - is three weeks away. Again, one appointment slot. Starting 5 weeks out there are multiple vacancies in a day.

That's a doctor that needs to stop taking new patients for awhile since they clearly can't handle their existing patient load.

 

[Ceke2002]

Bro. He's totally serious. It's months to see a PCP.

Going to be regional. Maybe in a rural rural area you can slide in next week.

In my area it’s about 3-4 months for neuro or GI. 3 months for any actual psychiatrist that’s not some fake nurse. We seem real saturated on cards. Can get an appointment in 2-3 weeks but they still do useless stress testing and stress is booked out 3-4 months. Some are using ccta but that’s even worse.

Once I moved here I tried to find a pcp. The top 5 recommended to me are 3-5 months for a new patient unless I wanted to see the mid level.

@VA Hopeful Dr can speak more accurately

VA here is taking 3-6 months to get new patients who've enrolled with a PCP in to be seen. Many of the PCP teams are headed by NPPs. Ortho is 2-3 weeks out for acute fractures, 6-9 months for routine visits. Routine (non-STAT) imaging takes 3-6 months to be performed.

On the private side, with good insurance, it took me 2 months to see a PCP with most PCPs no longer accepting new patients. Specialty services are hit or miss, derm takes months to get an appointment, I can see ortho next day.

Oh wow, I'm so sorry for what you guys have to go through. and the strain that must put on just everyone who works in the ED system as a result (not to mention your own healthcare needs as well).

 

[allantois]

Wait, what?! Are you serious? Like that wasn't hyperbole? If so then I gotta ask what sort of half ar5ed, dodgy brothers system have you guys got over there?

Just wow, yeah, sorry I'm absolutely blown away by that. I mean weeks to months to get an appointment with a Primary Care Physician even, I cannot even begin to fathom that.

No wonder all the debris ends up washing into your Emergency Departments.

I keep reading about this, however, this is not a universal experience everywhere. Last time I needed to see GI, derm, and get an ultrasound - I was able to schedule those apps the next day (and no I was not an established patient). I can squeeze in a patient the next day if needed for psych

 

[thegenius]

You mean the PCPs finally started seeing sick patients again instead of turfing them to the ED because they have cold- like symptoms and may have COVID?

We get multiple turfs to our small facility from the larger non-profithealth system’s physician group PCPs all the time. It’s getting to be comical.

No they don't.

Although I think i'm biased because all the so-called "sick" people sent to the ED by the PCP tend to be underinsured.

 

[allantois]

This is the care system in the US:

Good insurance = specialist

Bad insurance = PCP

No insurance = ED

 

[TooMuchResearch]

You mean the PCPs finally started seeing sick patients again instead of turfing them to the ED because they have cold- like symptoms and may have COVID?

We get multiple turfs to our small facility from the larger non-profithealth system’s physician group PCPs all the time. It’s getting to be comical.

No, the patients are all just too chronically ill.

 

[Ceke2002]

I keep reading about this, however, this is not a universal experience everywhere. Last time I needed to see GI, derm, and get an ultrasound - I was able to schedule those apps the next day (and no I was not an established patient). I can squeeze in a patient the next day if needed for psych

Here I can get a telehealth appointment within 2-5 days, depending on how busy a clinic is. In person appointments I can usually get same day. Any blood tests ordered also same day. I had to wait a week for an ultrasound appointment, but that was mainly because of the Easter break. Initial appointment with my Haematologist at a local cancer centre had a wait time of approximately 3 weeks. Waiting time for a PET scan and bone marrow biopsy was a week.

Glad to here the wait times over there aren't universally a complete disaster.

 

[RustedFox]

Here I can get a telehealth appointment within 2-5 days, depending on how busy a clinic is. In person appointments I can usually get same day. Any blood tests ordered also same day. I had to wait a week for an ultrasound appointment, but that was mainly because of the Easter break. Initial appointment with my Haematologist at a local cancer centre had a wait time of approximately 3 weeks. Waiting time for a PET scan and bone marrow biopsy was a week.

Glad to here the wait times over there aren't universally a complete disaster.

Jeeezus.

 

[xaelia]

Can't add much from personal anecdote for healthcare access here in Christchurch, but obviously I was able to register myself as a patient while working a shift to get myself an X-ray and see just how brokenated my toe was after having smashed it on furniture in the dark.

We've had no trouble registering with GP practices locally, and all my wife's various appointments for semi-acute things have been within a week. Judging from what I see in the ED, there are clearly some practices with lower availability for walk-ins – or just lower patience. Booking specialists through the public system is triaged by condition after referral – chronic knees/hips/hernias etc. will be months to be seen, then months (or more) to be booked for surgery. For approrpriate urgent- or semi-urgent or "high suspicion of cancer", these are currently all happening easily within days with appropriate pre-visit imaging etc.

We haven't really tried to use our health insurance/access the private side of healthcare in NZ, so can't much speak to that yet.

 

[Ceke2002]

Can't add much from personal anecdote for healthcare access here in Christchurch, but obviously I was able to register myself as a patient while working a shift to get myself an X-ray and see just how brokenated my toe was after having smashed it on furniture in the dark.

We've had no trouble registering with GP practices locally, and all my wife's various appointments for semi-acute things have been within a week. Judging from what I see in the ED, there are clearly some practices with lower availability for walk-ins – or just lower patience. Booking specialists through the public system is triaged by condition after referral – chronic knees/hips/hernias etc. will be months to be seen, then months (or more) to be booked for surgery. For approrpriate urgent- or semi-urgent or "high suspicion of cancer", these are currently all happening easily within days with appropriate pre-visit imaging etc.

We haven't really tried to use our health insurance/access the private side of healthcare in NZ, so can't much speak to that yet.

Yep, same here. If you want to see a Specialist in the public system, then you get triaged for urgency of condition. With my diagnosis of Marginal Zone Lymphoma the initial couple of rounds of blood tests did seem to indicate an indolent form of cancer, so a 3 week wait was appropriate. Had there been more of an indication that it was an aggressive form of cancer, I would've got in a lot sooner. When I needed surgery to diagnose and possibly treat suspected endometriosis (once pre-imaging/tests had ruled out anything more sinister) then that was about 2 months for the initial Specialist appointment, and then another 2 months wait for surgery. That was actually where I came across the (thankfully uncommon in my experience) instance of a private health cover patient being completely entitled, and acting accordingly - they wanted a private room, how dare they be made to wait for day surgery in the same room as other patients; they wanted better pillows, a more comfortable bed, higher quality sheets and blankets; they demanded a cup of tea and biscuits be served to them, regardless of NPO before surgery; they wanted to dictate exactly what pre-surgery medication was to be given, despite there being no medical indication; and all of this punctuated with constant reminders of, "I paid for this", and "Don't you know who my Doctor is" (a totally meaningless utterance since many Doctors here work both public and private systems). It was probably good she got wheeled off to surgery when she did, because quite a few us were starting to have trouble keeping our mouths shut & not just outright calling her on her bs with a stream of colourful language .

 

[Birdstrike]

We recently went through with this in my family. My mother-in-law has severe dementia and it's been progressing for years. My father-in-law insisted he keep her at home "'till the end." He managed for a long time. But as things worsened, he refused to get help, visiting nurses, in-home aids, etc. Both of this children live out of state (two families with physicians, including my own). Despite our trying to help him along to encourage him to maximize in-home help covered by his and his wife's insurance, he refused it all, including family, friend and neighbor help.

Despite her falling, breaking an arm, having 3 syncopal episodes (one with a head injury), one episode where she accidentally cut her with a knife and bled all over the for hours (because she forgot what bandaids were) driving her car, getting lost, wandering out of the house and being brought home by the cops multiple times, he refused all help (including attempts to arrange family help, albeit difficult with everyone living out of town). My wife was near the point of calling social services, as futile as that often can be, in an attempt to force placement.

Finally one day, my mother-in-law became incontinent of stool. As I predicted several years prior (to my wife), that reality was the thing that prompted him to finally put her in an assisted living. She's now actually doing much better in an environment where she's adequately cared for, having (temporarily) regained some speech, personality traits and signs of well being.

It's a very difficult thing to have to deal with, no matter what role you have in the matter.

 

[wareagle726]

Not to derail the previous trend of comments(@Birdstrike I feel your pain, we are going through a similar situation). I do want to get some input from ya'll because I feel like this is one of my most feared patient encounters. Been out 3 years now and I feel like I still don't know how to handle it. On the one hand its "yeah they haven't been able to take care of themselves for 2 months and you just flew in from Xville and found them not how they were a year ago" but on the other hand its me thinking "okay, I send 85yo gmom/gdad home because they've been this way even though family is insistent they can't go home"...but they're high likelihood to end up getting sicker soon anyway regardless of disposition. Doesn't matter though because if I send them home then I'm liable.

I know I'm probably way more conservative/naive in my though process but I just haven't mustered the determination to be like "nope, y'all are the family and it's your responsibility." Especially confounding is when none of the family can tell me anything about what the patient's baseline is, what meds/med hx they have, etc... Those cases make me feel like I would have no foot to stand on if legal counsel came back with "so you're going to tell me Dr. Wareagle, that you sent an 85yo home without knowing they had good support at home? For goodness sake nobody even knew what medication she/he was supposed to be taking."

 

[BoardingDoc]

Not to derail the previous trend of comments(@Birdstrike I feel your pain, we are going through a similar situation). I do want to get some input from ya'll because I feel like this is one of my most feared patient encounters. Been out 3 years now and I feel like I still don't know how to handle it. On the one hand its "yeah they haven't been able to take care of themselves for 2 months and you just flew in from Xville and found them not how they were a year ago" but on the other hand its me thinking "okay, I send 85yo gmom/gdad home because they've been this way even though family is insistent they can't go home"...but they're high likelihood to end up getting sicker soon anyway regardless of disposition. Doesn't matter though because if I send them home then I'm liable.

I know I'm probably way more conservative/naive in my though process but I just haven't mustered the determination to be like "nope, y'all are the family and it's your responsibility." Especially confounding is when none of the family can tell me anything about what the patient's baseline is, what meds/med hx they have, etc... Those cases make me feel like I would have no foot to stand on if legal counsel came back with "so you're going to tell me Dr. Wareagle, that you sent an 85yo home without knowing they had good support at home? For goodness sake nobody even knew what medication she/he was supposed to be taking."

Are you asking about strategies to dispo the "vaguely weak old person?"
- If they seem with it and can walk --> DC
- If they seem out of it and have a reason to admit --> Admit
- If they seem out of it and it's likely chronic --> ED obs for PT/CM evaluation in the morning for placement
- If they can't walk --> ED Obs for PT/CM.

I admit virtually none of these people. They board in their room if we don't need the space, they board in a hallway rather frequently. For the willfully non-ambulatory or the ones whose family is clearly pushing against the DC, I explain that they aren't being admitted, they are being put in observation (Medicare don't pay for that apparently) and will be hanging out in this brightly lit hallway until PT sees them in the morning and either discharges them home with services or sends them to a rehab facility somewhere.

 

[Arcan57]

Not to derail the previous trend of comments(@Birdstrike I feel your pain, we are going through a similar situation). I do want to get some input from ya'll because I feel like this is one of my most feared patient encounters. Been out 3 years now and I feel like I still don't know how to handle it. On the one hand its "yeah they haven't been able to take care of themselves for 2 months and you just flew in from Xville and found them not how they were a year ago" but on the other hand its me thinking "okay, I send 85yo gmom/gdad home because they've been this way even though family is insistent they can't go home"...but they're high likelihood to end up getting sicker soon anyway regardless of disposition. Doesn't matter though because if I send them home then I'm liable.

I know I'm probably way more conservative/naive in my though process but I just haven't mustered the determination to be like "nope, y'all are the family and it's your responsibility." Especially confounding is when none of the family can tell me anything about what the patient's baseline is, what meds/med hx they have, etc... Those cases make me feel like I would have no foot to stand on if legal counsel came back with "so you're going to tell me Dr. Wareagle, that you sent an 85yo home without knowing they had good support at home? For goodness sake nobody even knew what medication she/he was supposed to be taking."

Admitting a geriatric patient to the hospital is not a benign intervention. The risks are worth it if there's something specific that can only be fixed by an inpatient admission. By the time you're so debilitated that just being at your baseline gets you admitted, the chance that you're coming out of the hospital better than you arrived starts approaching zero.

 

[Ceke2002]

Not to derail the previous trend of comments(@Birdstrike I feel your pain, we are going through a similar situation). I do want to get some input from ya'll because I feel like this is one of my most feared patient encounters. Been out 3 years now and I feel like I still don't know how to handle it. On the one hand its "yeah they haven't been able to take care of themselves for 2 months and you just flew in from Xville and found them not how they were a year ago" but on the other hand its me thinking "okay, I send 85yo gmom/gdad home because they've been this way even though family is insistent they can't go home"...but they're high likelihood to end up getting sicker soon anyway regardless of disposition. Doesn't matter though because if I send them home then I'm liable.

I know I'm probably way more conservative/naive in my though process but I just haven't mustered the determination to be like "nope, y'all are the family and it's your responsibility." Especially confounding is when none of the family can tell me anything about what the patient's baseline is, what meds/med hx they have, etc... Those cases make me feel like I would have no foot to stand on if legal counsel came back with "so you're going to tell me Dr. Wareagle, that you sent an 85yo home without knowing they had good support at home? For goodness sake nobody even knew what medication she/he was supposed to be taking."

Not a Doctor, obviously, but I tend to agree with what Arcan57 said above.

Both my parents had dementia, both now deceased. One of them (my Dad) was only ever hospitalised for actual treatable conditions, such as pneumonia; the other (my Mum) landed in hospital under the mental health act and ended up needing to be boarded in a long term geriatric care unit whilst waiting for a residential care facility place to become available.

The difference between the two?

Well despite having mixed vascular and lewy body dementia, my Dad remained surprisingly ambulatory and only moderately confused ( hallucinations etc not withstanding) for the most part. Even towards the end, as long as someone was there to supervise and prompt him when needed, he still managed to mostly shower and dress himself, and prepare and eat simple meals. Most of the hallucinations he had were also fairly benign, at one point he thought the neighbours were beaming porno movies into the backyard, so just plonk him in front of the kitchen window & he'd be entertained for a couple of hours. There was also some paranoid delusions in the mix, but none that prompted any sort of serious outbursts of violence.

My Mum, on the other hand, apparently decided to attempt the world record speed run for dementia by going from diagnosis to end stage and death in less than a year. She also remained mostly ambulatory, despite physical frailness, but her level of confusion was such that forget anyone assisting her to make simple meals, I don't think she even grasped the basic concept of a sandwich. The biggest issue with my Mum; however, was that she became a genuine danger to herself and others. A newspaper headline along the lines of, "Dementia patient, wrongly discharged from hospital, beats neighbour to death", was a very real possibility. With that in mind having her remain in hospital until a care placement could be found was more about protecting her and the wider community, than trying to fix or improve anything beyond basic stuff like malnutrition and dehydration.

 

[wareagle726]

Are you asking about strategies to dispo the "vaguely weak old person?"
- If they seem with it and can walk --> DC
- If they seem out of it and have a reason to admit --> Admit
- If they seem out of it and it's likely chronic --> ED obs for PT/CM evaluation in the morning for placement
- If they can't walk --> ED Obs for PT/CM.

I admit virtually none of these people. They board in their room if we don't need the space, they board in a hallway rather frequently. For the willfully non-ambulatory or the ones whose family is clearly pushing against the DC, I explain that they aren't being admitted, they are being put in observation (Medicare don't pay for that apparently) and will be hanging out in this brightly lit hallway until PT sees them in the morning and either discharges them home with services or sends them to a rehab facility somewhere.

Totally get those options. What if you have no obs unit. New Job doesn't have ED obs and hospitalists are brutal with pushback. I have the exact same thought process but what about when you don't have one of those tools to use? I know there's no good answer FWIW.

Not a Doctor, obviously, but I tend to agree with what Arcan57 said above.

Both my parents had dementia, both now deceased. One of them (my Dad) was only ever hospitalised for actual treatable conditions, such as pneumonia; the other (my Mum) landed in hospital under the mental health act and ended up needing to be boarded in a long term geriatric care unit whilst waiting for a residential care facility place to become available.

The difference between the two?

Well despite having mixed vascular and lewy body dementia, my Dad remained surprisingly ambulatory and only moderately confused ( hallucinations etc not withstanding) for the most part. Even towards the end, as long as someone was there to supervise and prompt him when needed, he still managed to mostly shower and dress himself, and prepare and eat simple meals. Most of the hallucinations he had were also fairly benign, at one point he thought the neighbours were beaming porno movies into the backyard, so just plonk him in front of the kitchen window & he'd be entertained for a couple of hours. There was also some paranoid delusions in the mix, but none that prompted any sort of serious outbursts of violence.

My Mum, on the other hand, apparently decided to attempt the world record speed run for dementia by going from diagnosis to end stage and death in less than a year. She also remained mostly ambulatory, despite physical frailness, but her level of confusion was such that forget anyone assisting her to make simple meals, I don't think she even grasped the basic concept of a sandwich. The biggest issue with my Mum; however, was that she became a genuine danger to herself and others. A newspaper headline along the lines of, "Dementia patient, wrongly discharged from hospital, beats neighbour to death", was a very real possibility. With that in mind having her remain in hospital until a care placement could be found was more about protecting her and the wider community, than trying to fix or improve anything beyond basic stuff like malnutrition and dehydration.

The difference between my patients and you...you seem to have decency, sense, understanding that age is not the same as quality of life, and an idea of what health resources cost society.

 

[Mount Asclepius]

Totally get those options. What if you have no obs unit. New Job doesn't have ED obs and hospitalists are brutal with pushback. I have the exact same thought process but what about when you don't have one of those tools to use? I know there's no good answer FWIW.

ED obs is a billing avenue. You don’t necessarily need a specific unit or location. Both the initial EP and dispositioning EP can receive compensation. You just have to create tightly defined criteria/pathways and have buy in from those in your group. Allows you to better disposition and receive compensation for patients that are hard to admit or perhaps wouldn’t benefit from hospital observation/admission.

 

[BoardingDoc]

Totally get those options. What if you have no obs unit. New Job doesn't have ED obs and hospitalists are brutal with pushback. I have the exact same thought process but what about when you don't have one of those tools to use? I know there's no good answer FWIW.

The difference between my patients and you...you seem to have decency, sense, understanding that age is not the same as quality of life, and an idea of what health resources cost society.

Agree with mount on this one. I don't have an obs unit either. The patient simply stays in their room or gets moved to a hallway and their status changes to "obs." The morning doc sees them, writes an obs note to bill for it and PT/CM come and do their thing. If you don't have the option to put them into observation status (literally throwing money away) just have them sit there until the morning and sign them out. No difference between that option and mine, except in mine we get paid for it.

 

[SXMMD]

Admitting a geriatric patient to the hospital is not a benign intervention. The risks are worth it if there's something specific that can only be fixed by an inpatient admission. By the time you're so debilitated that just being at your baseline gets you admitted, the chance that you're coming out of the hospital better than you arrived starts approaching zero.

As a hospitalist I lose way too many of these patients to delirium related complications. Falls, aspiration pneumonia (after being doped up with ungodly doses of Seroquel or zyprexa for agitation overnight), c diff (because of all these gomers have UTI based on a poorly collected UA at the NH requiring empiric abx).

Don't blame the ED for admitting but for sure hospitalization is not a benign intervention for the elderly. Family members tend not to understand this until grandma is in the delirium death spiral.

 

[Ceke2002]

Totally get those options. What if you have no obs unit. New Job doesn't have ED obs and hospitalists are brutal with pushback. I have the exact same thought process but what about when you don't have one of those tools to use? I know there's no good answer FWIW.

The difference between my patients and you...you seem to have decency, sense, understanding that age is not the same as quality of life, and an idea of what health resources cost society.

Thank you, that's very kind of you to say. One thing I try and encourage everyone I know to do (sooner rather than later) is have an end of life care plan in place. I think in some parts of western culture we've almost become death phobic, as if refusing to acknowledge death will somehow prevent the inevitable for all of us.

My Mum had an end of life care plan drawn up about a decade before she got sick, and it made things so much easier in terms of decision making, not just for myself but for the healthcare professionals looking after her as well. She died from acute renal failure due to septic shock & there was nothing done treatment wise that Mum had not already discussed with me and other family members prior - do not resuscitate, do not intubate, treat only that which is immediately treatable, take no heroic measures.

Seriously end of life care plans are a necessity in my book, I really wish more people took the time to talk about them with loved ones & then have them set up in a way that clearly communicates their end of life care wishes to all concerned.