Caretakers Dozen: What Drives Patients Away from Primary Care

APRIL 18, 2019
Simon Murray, MD
Simon Murray, MDGenerally speaking, concierge medical practices are primary care practices that focus on personalized medical care by limiting practice sizes in return for an annual fee. The term “concierge” is not exactly correct, since these practices don’t valet park your car or provide fuzzy slippers, and won’t take your clothes to the laundry. They provide medical are that is unrushed, and personalized. Medicare, most major insurance plans, and the American Medical Association all consider it an ethical alternative to regular practice.

There are many different models that all offer same day or the next appointments, longer appointment times, and more communication with other physicians who are involved with their patient’s care. While some patients and doctors don’t agree with the concept, there is no doubt that anyone can benefit. In some models, physicians are allowed to take patients pro bono who couldn’t otherwise afford the costs of care.

In fact, there have been several clinical trials showing that concierge care patients report better results, with improvement in quality measures and fewer hospitalizations. Satisfaction rates of patients and doctors approach 90%, compared to patient satisfaction rates of 50% to 70% with standard care.

Most physicians, highly trained and well-meaning, don’t like the current US healthcare system. I have been around doctors for most of my life, and I know that patients are the highest priority for most. Even our institutions of higher learning are the envy of the world. But the system has become so corrupted, over-regulated, and user-unfriendly that a high percentage of primary care doctors would quit tomorrow if they could.

It's the system under which we operate that has soured the physician-patient dynamic. Despite the best doctor’s intentions, we are only judged by our actions dictated by a flawed process. But there is an alternative to standard practice which is worth at least investigating. Here are some reasons that a patient may be driven to alternative care such as a concierge practice.

1. The best advice they ever received when reaching out to their doctor’s office is, “If this is an emergency, hang up and dial 911, or go to the nearest emergency room (ER).”

2. If they call and managed to get a live person who answers, “Doctor’s office, please hold” before they can say word, they may consider changing practices. If the patient lives long enough to be taken off hold, only to be asked what insurance they have, that could be a deal-breaker as well.

3. They have to show a picture ID every time they actually get an appointment, because no one recognizes them from their last visit. That’s a clear sign their relationship with a physician isn’t a two-way street.

4. If it takes them longer to undress than it does for the physician to give an annual wellness exam, no one is going to confuse that with efficiency.

5. They leave every time with a prescription for azithromycin for every sniffle, cough, or sneeze reported. The patient is making the world unsafe by taking unnecessary antibiotics and promoting multidrug-resistant bacteria, and the doctor is making it clear they’re unfamiliar with a CDC guideline published 5 years ago urging restraint with antibiotics. Not a good sign.

6. The patient always leaves with either a specialist referral or a prescription for an MRI or blood test. The doctor is not “being thorough”—they’re behind schedule and moving patients out of the office with costly detours.

7. Patients are frequently sent to the ER when calling the office. Multiple studies have confirmed a tremendous overuse of ER services for problems easily handled in the office. If your office schedule is clogged by patients seeking referrals for routine eye exams or refills on chronic medications, there is no time to see patients with emergent problems. Good luck to the patient who gets a $17,000 ER bill for a migraine.

8. A patient spends a week in the hospital. He never learns a name of the dozen-plus physicians to have treated him for just minutes at a time, and he never sees his actual physician. He’s experienced the hospitalist system. If a doctor tells a patient they’re no longer allowed to go to the hospital, that is a nice way of saying it's not worth their while to go there anymore. Hospital stays are when a patient would benefit most from the reassuring oversight of a familiar doctor, and it’s one of the best opportunities for pair to develop a positive relationship. And yes, there are studies that show patients who have long-term relationships with their doctor actually live longer.

9. A patient visits an urgent care center more than once per year.

10. An office with magazines dated back to 2015, with no tissue paper in the bathroom and dying decorative plants implies the practice is dying, too. Buy some new magazines. You don’t want your waiting room to be like Disney Land: long wait, short ride.

11. The patient is interrupted seconds in to describing their symptoms. The current national average is 54 seconds before a patient is interrupted. A confident diagnosis requires a patient giving their full story, and that story usually takes longer than 54 seconds to tell. Interruptions occur when the doctor has already decided the diagnosis, and spends the remaining precious time with the patient trying to prove their theory right. It's not the way we normally talk to each other when we have a problem, but in the consultation room, it's standard practice.

12. If a doctor stands at the door with their hand on door knob while a patient relates more symptoms or concerns. When a patients asks a question while you’re leaving the room, and all you’ve got is, “Make another appointment,” they’re not going to make another appointment.

13. The office has more signs telling patients what the practice requires or restricts than there are diplomas on the wall. I’d wager that’s going to get patients ready to put on their gloves, not work together.

I’m happy for the patient at peace with their care, and the physician at peace with their practice. But if these minor frustrations are enough to drive a patient to another proven method of care, then you need to be ready to correct the problems.

Sure, most people actually forgive or forget bad experiences every time they get sick, and stick to the care they’ve always gotten. But is that any way to better the system?

Simon Murray, MD, is an internist based in Princeton, NJ. The piece reflects his views, not necessarily those of the publication.

Healthcare professionals and researchers interested in responding to this piece or contributing to MD Magazine® can reach the editorial staff here.


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