Jumping to Conclusions

Courtesy Noah Waldeck

One of the headlines in healthcare news this week came from a study just published in the journal Health Affairs. Researchers analyzed medical records (2001 to 2004) of over 300,000 patients, trying to find where they sought treatment for a variety of medical ailments. Now, I was expecting these patients went for serious ailments: chest pain, sudden abdominal pain, or other conditions we all might consider an emergency. I was sure that if it was a condition that needed attention soon, but was not necessarily life-threatening, patients would wait and seek out there personal doc.

Oh, how naïve I was! The study clearly showed these patients received care for these problems from their primary care physician less than half the time (42 percent) and that 28 percent of these folks went to the emergency department. Others sought out their specialist or went to an urgent (not an emergency but we can get you in now) care facility. A majority of these visits occurred on weekends (when most physician offices are obviously closed) or during the weekday evenings after offices closed. Not surprisingly—but sad on so many levels—patients without insurance sought more than half of their acute care in an emergency department.

One of the lead authors (an emergency room physician) believes part of the problem is getting timely access from our primary care physicians. If our primary physician can’t see us for a week, we know one place where they have to see us right now—the emergency room. Of course, we also know that walking in those doors and being seen quickly by a physician are not necessarily the same. If our problem is minor (it seems even the emergency department has rules on what they see first) it could be hours before getting what we consider proper treatment.

What the study couldn’t tell us is what went through the minds of those patients as they sought care. Was it purely convenient for them to go after hours; were they just trying to jump to the head of the line to get their problem addressed; did they truly think they had an emergency and that life or limb was at stake? Already the public policy experts, politicians and insurers are wringing their hands (and pocketbooks) and wondering how we can give timely and most important of all, less expensive access to care.

But to me the most important missing element in this access outcry is understanding the context of the patient. A patient arriving in their primary physician’s office with a problem, or for routine evaluations, allows the doc to build their human story. Collectively, primary physicians are continually shaping and refining the story of the person in front of them; what health problems they’ve experienced in the past. At a glance (and getting better due to electronic records) their personal physician knows their medications, prior procedures, family skeletons, what’s worked and what didn’t. Frequently, the doc quickly knows what is minor and fixable. When it’s serious however, they also know who to call and how to marshal the resources to get the care the patient needs in the proper place.

To the primary physician they’re not the stomach pain in Bed 3, but Joe who just got laid off and is literally worried sick about how he’s going to pay the bills and still get that kid to college. They know the human story of who Joe is and why something has gone astray. Thinking of health care access only in terms of time and place strips away the essence of what we can and should provide—caring for the person, not their symptoms. We all want health care fast but let’s measure success where it really counts, by knowing the story of those who seek our care.

About Steve P. Sanders

A general internist writing and sharing ideas and art.

One Response to “Jumping to Conclusions”

  1. Good thoughts Steve.
    I read the series of articles in the OK State Med Assn Journal named “Narrative Medicine” and recently a published copy of all articles arrived. I think this could be one of the most important pieces a doctor in school or training should read. We need deductive logic thinkers who have access to a data source, in him mind or computer, that he can draw upon for accurate conclusions.

    Recently I heard Dr. David Kendall, OU Med Tulsa, who is working on “doc to doc” networks. He and cohorts have come up with a “safety net” concept. One really lacking relationship is between primary care providers and specialists as they work with the indigent. He has data on how computers improve the communications, level loads, make information available, for this problem.

    These two concepts should reduce the problems described in your blog.

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