I had a patient in my office today and I was not sure why. She had a very simple, straightforward, common health problem. A cardiologist certainly was not needed to evaluate her. No fancy testing was required. No treatment was indicated. I reassured her and sent her on her way, relieved and happy.
I see this every day. Multiple times a day. People with simple problems sent to a sub-specialist by their primary care practitioners. Why?
For a while, I blamed myself and my generation of medical educators. Obviously we had sent young doctors and practitioners out into the world poorly trained, lacking in basic knowledge, or limited in physical examination skills. However, the more I talked to these primary practitioners and spent time visiting them in their offices as a PATIENT, the more I realized they were very bright, skilled and well-trained individuals. No, the teachers were not at fault. The former students were not to blame.
The problem is the clock.
The typical primary care practitioner in this country lives and dies by the 15 minute appointment. Patients are booked in multiples of 15 minutes because the system demands it and requires it. It takes VOLUME to be financially successful in the practice of medicine in America especially if you are in primary care. You simply do not have the time to speak to one patient for more than a few minutes. You must speak quickly to many patients in a few minutes. Those people who control our lives as doctors in the clinic setting I unfortunately have come to refer to as “bean counters”. The bean counters have come up with the 15 minute visit. The problem is that bean counters have never taken care of the sick, the anxious, the well simply looking for advice.
So, the people I see in my office now are those that will take a primary care practitioner longer than 15 minutes to evaluate. Those patients can easily be evaluated by a generalist who is given a few minutes to get a proper history, a few more minutes to truly examine the patient and then, importantly, an adequate time to discuss the situation, give advice and reassure the patient that all is well or will be well after a little bit more information is obtained.
In my office, this is available. I am a sub-specialist. The bean counters count my beans differently than they count the primary care doc’s beans. I have no 15 minute appointment slots — and I fight daily to keep it that way. The reimbursement system “pays” me more for my 15 minutes than my generalist colleagues. Furthermore, I have TESTS that I can do. Lots of tests. I am a cardiologist! I live to do tests — EKGs, echocardiograms, TEEs, caths, EP tests, tilt tables, stress echoes, stress tests, nuclear tests etc. etc. Every test I perform brings in more beans for the bean counters to count. They tend to like cardiologists quite a bit.
So, the entire system has conspired to move patients out of the primary care office and into the sub-specialist’s office. This is exactly what the system was NOT supposed to do. Primary care MANAGERS (as they are called now) are, in my opinion, are nothing more than triage officers. The practice of medicine has forcibly been yanked away from them. They parcel out people to specialists.
The primary care folks that I hang around with detest it. They want to PRACTICE medicine. But they know that as long as they hear the tick, tick, tick of the clock louder than the voice of the patient, their practice of medicine will be frustrating, empty, and without joy.