EM vs. Primary Care, Which is Best for the Public

[docB]

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Its kinda interesting that family medicine residency programs are being closed down and new emergency medicine programs are springing up....mirroring the trends of today's pts who avoid their PCPs and run straight to the ER for anything.

I never thought of it that way.... this should be a separate thread.
Is there a way I can automatically 'bump' it to its own?

That’s a good question. Would it be better for the public to cut back on EM residencies and expand on primary care residencies? Maybe. That was definitely the feeling when I was in med school as was demonstrated by the special loans and benefits you could get if you indentured yourself into primary care.

Remember that we’re talking about benefit to the public and not to nervous med students with match anxiety.

 

[beyond all hope]

I am lucky to work in an area where almost all of my patients have PMDs who are pretty easily accessable. I write things like 'see PMD 1-2 days' and it actually happens!

However, we still need EM docs. I find it doesn't make all that much difference if the pt calls the PMD beforehand. Docs can't handle urgent/emergent stuff in their office, even if they feel capable of doing so (no monitors, no consults, no critical care in case something goes wrong)

It certainly wouldn't hurt to have more primary care docs. What is happening now is that most of our PMDs are FMGs. Many FMGs recieve training that is equal or even superior to american grads, but there is frequently a significant language and cultural barrier between them and their patients.

The real fix for this is to change the billing system so that primary care could actually make money. I bill most of my charts at level 3-5, +/- procedures. PMDs probably are billing at 1-3. How the heck can you make money that way?

 

[Mac11]

I think primary care is better for the public. A primary care doc would have to look at why you have ___, not just how to treat the symptoms (extremely generally). An EM doc would be happy to treat whatever you have at the moment and then send you away. So long term, a primary care doc is better for the pt. Although both have their uses; a lot of people get too worked up with all the ifs. (I looked on some random "ask a doctor" website - honestly 99% was people asking "what if...?")

I'm not even in med school, so take whatever I say with a grain of salt. I just read something similar nearby and it made sense to me.

 

[docB]

I asked this because it’s evident to me that primary care has failed and EM is expanding to pick up the slack. Let me qualify that with some flame ******ant by noting that the doctors in primary care have not failed (except for a few who I have to deal with). The medical system has been unable to match patients up with doctors, give them easy enough access to those doctors and educate the public properly about what constitutes an “emergency.” Consequently patients rattle around the system and overflow into the ED. I have long maintained that we as EPs are very expensive, poor quality primary care doctors.

Now since because primary care has failed and all those patients who should be being seen in a clinic are in the ED our numbers are up. That increases our pay and puts up in higher demand. That’s why there is a push for more EM residencies and primary care residencies are closing up. I would argue that from a community sense this is bad for the overall condition of medical care.

 

[beyond all hope]

It's true that more PMDs are better for the public. The PMD knows the patient and can frequently pinpoint chronic conditions far better than an ER doc.

There is a reason I don't get involved with chronic medical complaints. It's not that I don't care. If I have to, I will. I have prescribed HTN meds, DM meds (even started these regimens), allergy meds to those who can't/won't see a PMD.

This can lead to trouble. Many people will simply show up in the ED whenever they have any complaint, get a random prescription, and are sent home. They think it's more convenient and faster, but this leads to big trouble.

Case in point: saw a young woman yesterday with a hundred cheif complaints. Earlier she had gone to an ED, recieved levaquin, and had a seizure afterwards. She came back to the ED c/o seizure, was told it might be due to the Levaquin (?), HCT negative, given Dilantin. She had told a covering doc that she had fever and a headache, was given a phone prescription for Amoxicillin for sinusitis.

Her primary complaints in the ED were diarrhea and fever. She looked basically well and was nontender so I sent her home on PO flagyl, FU w/stool toxin for C.diff. If I was a PMD I could have made the distinction between antibotic diarrhea, viral syndrome diarrhea, IBS, C.diff, etc. Lucky for me we have a followup office who will call the patient if the C.diff is postive or negative.

With my luck she'll drink EtOH with the Flagyl, come into arother ED vomiting, get a CT scan and get an allergic reaction to contrast or be given compazine and have extrapyramidal side effects...

A good PMD could have gotten to the bottom of all of her complaints, and given her the appropriate treatment (perhaps a smack to the side of the head and admonishment to suck it up). I don't have the time or the perspective. She's nonemergent so I treat her and move on.

 

[Febrifuge]

The medical system has been unable to match patients up with doctors, give them easy enough access to those doctors and educate the public properly about what constitutes an “emergency.” Consequently patients rattle around the system and overflow into the ED. I have long maintained that we as EPs are very expensive, poor quality primary care doctors.

I say the exact same thing, in my little "talks" with patients as I'm rolling them over to XRay (and when they initiate the talk). You're waiting three hours in Triage and two hours back here because you have to. You have to because that's the way it is. That's the way it is because you came here, as opposed to somewhere more appropriate. (Yes, I'm paraphrasing; it's a nice professional little chat.)

It seems clear the issue is getting the resources (the FP providers, the facilities) to the people who need them (I bristle at ever calling patients "customers" for many reasons; maybe worth yet another thread).

I think every new ED that's built or old one that's renovated should come with a decent Urgent Care within 200 yards, with at least a few staff people working some shifts in both places. That's how we have it, and from 9am to 5pm the ED has a fairly high level of actual emergencies. There's a clear "dump" that happens later in the day, and even with no sense of time you'd know when the UC has closed.

 

[Miami_med]

I think the problem has to do with the fact that the role of the Primary Care Doc is in flux. My wife's grandfather started practicing internal medicine in the '60s. At that time, if a patient had an urgent complaint, he would meet them at a local ED and take care of it. This was good for the patient and was profitable for him at the time. This really makes sense. The ED doc is there to handle emergencies beyond the scope of practice of the PMD, but the small complaints were handled by the PMD in the ED (with all of the ED resources). At the time, he carried a patient load 1/3 of the size of a modern PMD, lived on an island, and spent a month a year in Europe. His financial position allowed him to be there after hours for those emergencies. His smaller patient load allowed him to do that and still get adequate sleep.

 

[McDoctor]

I am lucky to work in an area where almost all of my patients have PMDs who are pretty easily accessable. I write things like 'see PMD 1-2 days' and it actually happens!

However, we still need EM docs. I find it doesn't make all that much difference if the pt calls the PMD beforehand. Docs can't handle urgent/emergent stuff in their office, even if they feel capable of doing so (no monitors, no consults, no critical care in case something goes wrong)

It certainly wouldn't hurt to have more primary care docs. What is happening now is that most of our PMDs are FMGs. Many FMGs recieve training that is equal or even superior to american grads, but there is frequently a significant language and cultural barrier between them and their patients.

The real fix for this is to change the billing system so that primary care could actually make money. I bill most of my charts at level 3-5, +/- procedures. PMDs probably are billing at 1-3. How the heck can you make money that way?

Even if you have the capability to do procedures in the office, it is often a contentious battle with insurance companies to get reimbursed for some of them. If you bill a level 3 E&M with a modifier 25 and a relevant procedure, insurance companies will many times only reimburse either the diagnosis related E&M or the procedure, but not both on the same visit. (Of course, they pay which ever one is less amount of dollars). Thus, lacerations end up getting turfed to the ER. Its hard to expect family doc's to do something they won't get paid for, especially when the procedure carries at least some risk of liability.

Alot of ED referrals from PMD's are also borne out of knee-jerk liability fears. Some PMD's grumble that they don't get paid for phone consultations with a patient, and this probably leads to unnecessary ER visits as well. I agree that a payment system that skewers away from proper reimbursement for primary care services is largely responsible for clogging up youe ER's.

I do want to point out, however, that the local ER's in my area heavily advertise in a manner that actually attracts non-emergent patient visits. When you promise that a patient will be seen within thirty minutes, then don't complain when they show up in droves asking you to remedy their sore throats and ear infections in a manner akin to ordering takeout.

 

[mlw03]

I have long maintained that we as EPs are very expensive, poor quality primary care doctors.

Great discussion topic!! I very much agree with this poster's views and have also said the emergency medicine is often very inefficient primary care for the poor. As to the original question, I feel more access to PCPs would be better for the public - I don't know if simply having more of them is the answer. How to do this I don't know. Charity-based clinics help, but they're a band-aid, and there's simply too many people out there without access to primary care.

Simple example of how that gets expensive: patients presents to ED with cc of 'chest pain.' Chest pain protocol gets begun (a few labs, ECG, maybe some cheap meds like nitro and ASA). You talk to the patient and get a history (which costs NOTHING to obtain) classic for GERD and tell them to take some OTC PPI or H2-blocker. The PCP would have reached the same conclusion without the expensive tests, but because the patient presented to the ED the EM docs have to r/o an MI. Same solution, a lot more $$ spent to get there. Had that patient had a PCP they saw every 6 months this could have been dealt with there much cheaper.

Again, great discussion topic. I doubt we're going to solve this problem here, but it's nice to know we care enough to take time out of our busy schedules to discuss it.

 

[Hard24Get]

Of course, we all know what the ultimate "solution" is to unequal access to medical care. Say it with me now.....

Great discussion topic!! I very much agree with this poster's views and have also said the emergency medicine is often very inefficient primary care for the poor. As to the original question, I feel more access to PCPs would be better for the public - I don't know if simply having more of them is the answer. How to do this I don't know. Charity-based clinics help, but they're a band-aid, and there's simply too many people out there without access to primary care.

 

[deleted87716]

Of course, we all know what the ultimate "solution" is to unequal access to medical care. Say it with me now.....

"Soylent Green is people!"

Oh, sorry...you were thinking of another kind of green? 😉

 

[mlw03]

I asked this because it's evident to me that primary care has failed and EM is expanding to pick up the slack. Let me qualify that with some flame ******ant by noting that the doctors in primary care have not failed (except for a few who I have to deal with). The medical system has been unable to match patients up with doctors, give them easy enough access to those doctors and educate the public properly about what constitutes an "emergency." Consequently patients rattle around the system and overflow into the ED. I have long maintained that we as EPs are very expensive, poor quality primary care doctors.

Now since because primary care has failed and all those patients who should be being seen in a clinic are in the ED our numbers are up. That increases our pay and puts up in higher demand. That's why there is a push for more EM residencies and primary care residencies are closing up. I would argue that from a community sense this is bad for the overall condition of medical care.

Of course, we all know what the ultimate "solution" is to unequal access to medical care. Say it with me now.....

as an undergrad i had always felt strongly that universal health care was the way to go - then i took a course in the sociology department on sociologic issues in medicine, and my perspective is much more undecided now. The short answer, IMO, is that there are pluses and minuses to the US vs. Canadian vs. European modeals, and to say one is definitively better than the other is something I am unable to do.

Someone made a point about educating the public about the role of the ED, and I think that's key also.

 

[bartleby]

To paraphrase John Donne, no doctor is an island, entire of itself. Gone are the days of the GP with no hospitals, CT scanners or bloodwork, when one person was the surgeon/internist/ob/psychiatrist and tasted urine in lieu of the dipstick. Medicine as it is known in the USA is a body of knowledge and practice which, for better or worse, is beyond any one person. PMD's deal with things that I don't have the time or interest to deal with, and all the internists I know feel the same way about what I do. Everyone has their own niche in medicine these days.

I do know that if the falling reimbursement for primary care is not reversed, that the aging baby boomers are going to be in deep doo doo as it is. Sometimes having 6 specialists who each manage their own organ system but miss the big picture issues is as bad as having no medical care at all. As I explained to someone the other day who expressed frustration at winding up in the ED when playing phone tag with three of his specialists said, "Sorry, I don't treat that", THIS is why he needs to find a PMD and keep him or her in the loop.

...but because the patient presented to the ED the EM docs have to r/o an MI. Same solution, a lot more $$ spent to get there....

Sorry... I'm going to call you on this one. First of all, everyone with reflux does NOT get labwork drawn in the ED. Would it be less expensive for the system for a young healthy person with GERD to go their PMD? Sure. But If you're 70 with multiple CAD risk factors, and an unclear hx, it's a different story. They wind up getting sent to the ED anyway.

 

[AmoryBlaine]

PMD is definitely better for public health. If we were only allowed to have one kind of doctor in the world we would want it to be true primary care docs (i.e. FP, Med/Peds). It's still heart dz, cancer, and Big Macs that kill everyone...

That said, it's nice to have a place where grandma get get her MI taken care of and where you can go after you get into a hi-speed MVA...

 

[Jeff698]

That said, it's nice to have a place where grandma get get her MI taken care of and where you can go after you get into a hi-speed MVA...

And where you can go to actually be seen by a physician when you need to. The reason so many people come to the ER with non-emergency conditions is because we are one of the few places left in the country that offer unscheduled phyician access. Sure, there are some primary care clinics that offer same day access (and God bless 'em!), but most don't. Even the 'open access' clinics are closed at night.

People come to the ER, not because they don't have insurance, but because they don't have access elsewhere. Plus, there are some true emergencies out there as well.

BTW I'm not raggin' on PCPs here. I understand the pressures they're facing as well. This is medicine's collective fault for letting MBAs make health care decisions. We bought into the HMO thing big time because we thought it was better than government control. I think government control would suck too, but I know HMO control sucks. Here's hoping we find a solution that doesn't suck.

Take care,
Jeff

 

[kate_g]

The reason so many people come to the ER with non-emergency conditions is because we are one of the few places left in the country that offer unscheduled phyician access.

I've been wanting to make a comment akin to this since the thread was started, now I can't resist... Here's a patient perspective. All but one of the ED visits in my lifetime has been a "non-emergency". Like, got my hand caught in a moving set piece, shut my finger in a car door, wrenched my ankle really badly skiing. Broke my toe. Had a simple lac that wouldn't stop bleeding despite my best attempts at elevation and pressure. Urgent, maybe, but hardly life-threatening. I have insurance, I have a PMD, they probably would even squeeze me in same-day if I asked. But here's the thing... My PMD's office is open, what, 8-5 M-F? Well, I don't typically hurt myself during office hours, because I'm sitting at my desk doing nothing during that time. I hurt myself during my lesiure time... which is also my PMD's leisure time! Most often it's something I'd even be comfortable leaving until morning, but if that something happens on Friday or Saturday, I might not be comfortable waiting until *Monday* morning.

Where I was an undergrad there was a 24-hour "urgent care" clinic. Last time I thought I might have to go to the ED, I actually took the time to call my insurance company to see if there wasn't someplace like that within their "network" that I could go instead. There wasn't. I still have kind of a hard time believing that. I live in the SF Bay area... I can think of four hospitals within 15 minutes of my house in the east bay, and there are probably some others I don't know about. And no urgent care clinics my insurance will cover? Well, it means the next time I think I might need an x-ray or sutures after hours, I'm probably coming to the ED...

 

[GeneralVeers]

I have no problem with seeing "urgent" cases in the ED, like lacerations, sprains, small fractures, etc.

The things that bother me are minor colds, med refills, and "my doctor sent me here for this test" cases.

I had one lady yesterday who finished using crack, so then drugged herself up on Vicodin. She called 911 and told paramedics to take her to the hospital so she could "get more vicodin". Needless to say she was discharged out the door fast.

 

[docB]

I've been wanting to make a comment akin to this since the thread was started,... And no urgent care clinics my insurance will cover? Well, it means the next time I think I might need an x-ray or sutures after hours, I'm probably coming to the ED...

I'm with Veers. We are happy to see minor trauma. We're good at minor trauma. I can fix lacs and sprains and breaks and dislocations and so on. If your injury turns out to be a contusion instead of a fracture no biggie. What I (we) hate are the chronic problems that we can't fix.
-I'm old and I don't feel good.
-I don't take my insulin and my sugar is high.
-I don't take my seizure meds and I had a seizure.
-My feet have been swollen for 10 years.
-I have COPD, I still smoke, and I feel short of breath.
-I have chronic pain and I like some drugs.
and so on.

 

[GeneralVeers]

I'm with Veers. We are happy to see minor trauma. We're good at minor trauma. I can fix lacs and sprains and breaks and dislocations and so on. If your injury turns out to be a contusion instead of a fracture no biggie. What I (we) hate are the chronic problems that we can't fix.
-I'm old and I don't feel good.
-I don't take my insulin and my sugar is high.
-I don't take my seizure meds and I had a seizure.
-My feet have been swollen for 10 years.
-I have COPD, I still smoke, and I feel short of breath.
-I have chronic pain and I like some drugs.
and so on.

You forgot the ever popular: "I'm hungry, I demand food now!"

 

[mikecwru]

You forgot the ever popular: "I'm hungry, I demand food now!"

You should see my discharge instructions: "You are being discharged. The cafeteria closes at 7pm."

mike