Primary care doc - necessary?

[Scuba]

We live in Palm Springs, CA and DH’s recent hospitalization made us reconsider the wisdom of relying on our current primary care doctor who is on the So CA coast. Before when we thought we were healthy, it didn’t seem like a big deal, but now we are thinking we need local docs.

I spent most of the day yesterday calling around. There are almost NO primary care docs in the entire Coachella Valley accepting new patients, and the few who are have been in practice just 2-4 years. This includes “concierge” programs that cost a substantial amount to join.

It’s just amazing to me that this situation is so prevalent. I’ve gotten referrals from quite a few friends, and none of their docs are taking new patients.

I have a GYN, a dermatologist and an ortho/sports med doc. DH will definitely get set up with a cardiologist following his recent heart surgery. I suppose one option is for one of our specialists to monitor our routine blood work and refer us to appropriate specialists as needed. We could just go to urgent care or the ER if something comes up that warrants immediate attention.

Given that we can’t seem to get primary care doctors who have any reasonable amount of experience, do you think we actually need primary care docs? Is this a problem in your area and if so, what are you doing about it? The docs out here don’t even take waitlists as many have not accepted new patients for over a year.

We have PPO insurance with great coverage so that is not the issue. We are too young for Medicare.

 

[tulak]

I don’t have good advice, but I ran into the same problem after my doctor retired last year.

I was lucky and got the same doctor as DS. The only reason is because they make an exception for new patients if there’s an existing relationship with the family. Otherwise I would have ended up with a younger doctor outside of my immediate area.

 

[Jerry1]

I believe that a primary care physician is an important part of my medical team. I can think of some alternatives, like an OB/GYN is often a primary doctor. You situation, however, is not unique. The retirement of physicians is happening and the supply is shrinking. My primary doctor is my age, early 60’s, so it concerns me. I’m especially concerned because my primary care doctor, an MD, is also a holistic practitioner. He was hard enough to find. I’m not looking forward to finding a replacement. I do some some mentoring going on in his practice, but it’s hard to envision it will be enough. AND, my doctor doesn’t take insurance. I pay him per visit, twice a year, but thankfully, the lab work is covered by insurance, just not his office visit. I guess the answer is to start looking sooner than later for an alternative.

At some level, the model may change, but I do think it’s important to have some continuity in who you see, even if it’s a physician practice versus an individual doctor.

 

[Car-Guy]

I have a PCP but the specialist(s) I see have never talked to him. Sooooo?

 

[Irishgirlyc58]

What about a nurse practitioner or physicians assistant for a PCP?

Also, what is your apprehension about doctors being young?

 

[Bamaman]

I went through all of the recent medical charges we've run up, and I can understand why many physicians don't care to deal with Medicare and/or Supplement Plans. They often just get paid a pittance of what an office call is worth.

We moved 2 years ago an hour away from my wife's PCP. After COVID hit, he went to online medicine, and he says he's never going back to face to face medicine if he can help it. We did visit him in person today, and he was reading all of her hospital medical records online in real time.

See if the PCP is practicing long distance, internet medicine.

My wife's being serviced otherwise by a local cardiologist and he got her into a pulmonologist yesterday who's going to do some baseline testing.

My PCP was the second doctor in his practice to retire last month. I'm watched by an endocrinologist very closely every 3 months. For sniffles, etc. I can go to a Doc in the Box locally.

Watching one's healthcare is of the utmost importance. But times are changing, and we sometimes have to roll with the flow and do things a more modern way.

 

[ivinsfan]

Scuba did you DH make back to your home yet? This is an important question but you can think about it for awhile, try not to spend time doing thinking about stressful or worry some things. Your don't need to do anything about doc or your HI today. I think you are having a stress reaction about what's been happening.


This is exactly what I did in your shoes but it just makes stuff worse. Your and you DH will have lots of recovering to do in the weeks ahead. It will get better as time passes but in the meantime it can feel overwhelming and like there is a problem waiting for you around every corner. I hope you both have a good weekend.

 

[Freedom56]

With PPO insurance you don't need a primary care doctor. However, you should have a competent doctor designated for annual check-ups who specializes in internal medicine or cardiology. We drive to West Los Angeles (about 35 minutes) to see our doctors because better quality doctors are at the major hospital system in Los Angeles (UCLA, Cedars-Sinai, USC-Keck). The quality of local doctors 5 minutes from our home are abysmal so we don't mind the drive. I was seeing a doctor who specialized in sports medicine (internal medicine) for the last 23 years at UCLA. He was really good and he focused on my overall fitness and cardiac health took a lot of time during my annual checkups. He was a professor and the clinic director at UCLA. He ran me through all the screening tests that I needed according to my age. He always followed up with my after my check-ups. But he retired and stopped seeing patients starting last November and so began a search for a new doctor for annual check-ups. I saw another doctor at UCLA for my annual check-up last December but I found him to be completely unsuitable. He saw me for the first time and said I was in good shape and listened to my heart and lungs, tapped my back a few times, and my physical was over in 10 minutes. He ordered a minimum set of blood tests. My wife who sat in the office with me was perplexed and then angry. His office billed $1831 to my insurance for the visit plus another $432 for the blood test. I looked at the EOB and found that the office billed for services never provided such as advance care directive planning, and an additional office visit. I felt cheated considering how much we pay for our PPO, the lack of subsidies, and how little time was spent with the doctor and the egregious overbilling. One call to UCLA customer service wiped out all the excess charges after I threatened to report the office to the State of California. So my search continued for a primary care doctor and I decided to see a doctor at Cedars-Sinai who specializes in cardiology and internal medicine. He seemed okay and gets straight to the point. His billing fees were reasonable. My only concern is his age as he will retire one day and I will be back to searching. He looked much younger in his profile photos than in person. Time will tell if this new doctor will work out. Southern California has many great hospital systems. Three of them are in the top twenty in the country. Driving about thirty minutes to one hour to see a competent doctor at one of the countries best healthcare systems one or twice a year is well worth the effort.

 

[swakyaby]

I think having a primary care doc is important in overseeing DH’s overall care. His cardiologist will be managing all things cardiac and other related internal medicine issues. But making sure he is being screened timely for other issues like prostate problems or colon cancer or diabetes may fall outside the scope of care for his cardiologist. Even though he is not in an HMO where there is a gatekeeper for referrals, specialists will want to know who his PCP is so they can send their reports to the person coordinating his care. I would consider a PCP relatively new to practice for myself if it appeared the other option is not to have one at all. But I would ask his cardiologist if there is a local primary care doc he/she would recommend. Then, when you do call that PCP office, name-drop the cardiologist’s name, saying “Dr ____ referred me to make an appointment with you as a new patient.” Sometimes, just having the referral coming from a specialist is enough to get your foot in the door.

 

[Mark1]

..... There are almost NO primary care docs in the entire Coachella Valley accepting new patients, and the few who are have been in practice just 2-4 years.....

We are a little lite in the local area with PCPs and a few fields of specialists; in fact we had to "apply" for a PCP when we moved to town. We ended up with a young doctor who we like very much, so I wouldn't sell the young folks with 2-4 years experience short. The younger PCPs have two advantages over the more seasoned doctors, 1) they went to medicail school more recently; and 2) they might still be in practice at the time of your death so you will never have to face this issue again.

 

[BuysToys]

After losing two PCPs due to retirement, I intentionally chose someone younger this time. I use a Nurse Practitioner who is very competent.



I have to use a PCP since I'm in a HMO plan. Even if it wasn't required, I'd still use one. I have several specialists and there are some issues that overlap. My PCP makes certain things don't drop through the cracks and that I get all the testing needed at the right time. Even though I don't use her for my cancer follow ups, she checks with me every year to make certain I've had them and reviews the results. She was the one who caught my symptoms and referred me to an OB/GYN rather than doing my pap smear a couple of years ago. I think she would have caught it as well, but I appreciate the referral.

 

[Aerides]

Since at worst you'd only be waiting till 65 (when, presumably, options might open for you), it doesn't sound like a bad idea, you can cover everything you need with specialists, and monitor your own blood tests, until something goes wonky.

But...if you need to have surgery of any non-emergency kind, your surgeon and/or the hospital will require clearance from your PCP - at least mine did when I had my knee tear fixed. So I had to go to her, do bloodwork and a basic checkup, and she signed off before the surgery could be confirmed.

Also, for run of the mill stuff, like a fever, or a bad flu, only a PCP handles that I think. So In your case I'd keep the one you have, since you hopefully can drive there if needed (or at least one of you can, or Uber).

But yeah, were it not for my knee surgery, I have not seen my PCP in over 2 years. I have a PPO, and I have seen my Gyno/Mammo/Derma/Ortho's and had them prescribe bloodwork, paid $50 for another test myself that they didn't cover, and I can see all those results on Quest's site along with my history, so I can see changes. Still, if I did see a change, or something go out of normal range, besides Dr. Google, I think a PCP would be my first stop then.

However, in your case with your DH's recent episodes, I'd keep looking. Assume you've tried calling your plan for choices?

 

[Dash man]

The PCP DW had in 2004 probably saved her life. We knew something was not right and she’d been experiencing discomfort in her abdomen. She tried to make an appointment with her gyn, but couldn’t get in for six weeks. She went to her PCP who evaluated her, called her gyn saying she needs to be seen today! Suddenly an appointment was available! Within two days we were speaking with a top notch gynecology oncologist. Two weeks later she had two cancer tumors removed, one ovarian cancer and on uterine cancer. She’s still with me today!
Having a PCP willing to go to bat for you is priceless!

 

[Car-Guy]

^^^^^Glad that worked for you but OTOH, my drug company decided they would no longer pay for a particular drug that I had been taking for over a decade. They said I now needed to take a much less expensive generic, which I knew, and my doctor knew, would not work for me. My PCP argued the case for me but they still said no. So I now pay full price for the brand name out of pocket.


And another interesting point, my insurance company says on my policy that I do not need to select a PCP and no referrals are needed... I'm sure if they thought it would be a savings to them they would demand it.

 

[OldShooter]

... Given that we can’t seem to get primary care doctors who have any reasonable amount of experience, do you think we actually need primary care docs? ...

With respect, this is not a very logical question. You can need a primary care doc and not be able to find one. You can be able to find one and not need one. The two concepts are independent.

 

[disneysteve]

Primary Care doc here. Yes, you need one. Everybody needs one. You can get specialty care from specialists. You can get acute care from urgent cares and ERs. But you need somebody running the show, overseeing everything, compiling all of the data in one place, and helping to put the pieces together. Your cardiologist isn't going to check your prostate. Your gastroenterologist may miss your thyroid condition. Your urologist won't notice that suspicious mole on your back. Your orthopedist isn't going to have a clue what to do about your ingrown toenail. A good PCP will address all of those things, and if he/she can't, will send to to the right person who can.


All of the specialists don't talk to each other, but they all talk to your PCP in the form of consultation reports. Your PCP is the hub of the wheel.


As for a younger/newer PCP, go for it. I'm a old doc and I can tell you that the newer ones are much more with it, much more up to date on current treatments and guidelines, generally more tech savvy. What they lack in experience (which is absolutely important) they make up for in current knowledge. I've learned quite a bit from my younger colleagues. Of course, I've taught them a lot too, but what I've taught them has been more experiential and what they've taught me has been more fact-based.

 

[Another Reader]

If you live in an area that is overwhelmingly dominated by vertically integrated health care systems as I do, your PCP choices are concierge and one of the systems. Here it's Kaiser, Sutter Health and Stanford. Medi-Cal, which is California medicaid, contracts with Kaiser in the local counties. Enough said. The other two follow flow chart medicine, as dictated by the insurance companies and Medicare. Finding a specialist outside of these systems can be difficult. Some will allow self referral, some do not.

 

[ShokWaveRider]

We have so many choices here in N.E. FLA., all within 5 miles radius that it is a toss-up. We go to a PCP for Regular Blood Tests and prescription renewals. But book directly with specialists as we need them. The longest we have waited for an appointment at any is 1 week, and 2 weeks for any given procedure that we needed.

 

[OldShooter]

... you need somebody running the show, overseeing everything, compiling all of the data in one place, and helping to put the pieces together. ... All of the specialists don't talk to each other, but they all talk to your PCP ...

This! !! From a project management perspective, the medical establishment is a clown show. DW's brother ended up in intensive care waiting for a heart transplant. We spent most days in the ICU waiting room, watching the specialists come and go with no one in charge and never talking to one another. Every day a guy from the pharmacy would come up and spread out the meds orders to make sure the docs weren't screwing each other up. That was the extent of the coordination. The only one really in charge in the sense of knowing what was going on was a nurse. He was not afraid to call the docs' attention to issues but the ego hierarchy left no one really in charge. I'm not sure this chaos can be blamed for BIL's eventual death, but it did not help.

So ... we are in a concierge practice specifically to have some project management capability in our hip pockets when we need it. When DW had a hip replacement her/our PCP reviewed her hospital staff notes and called her every day for a check-in. The nurses were blown away; they had never seen a PCP who did this. He would have visited her in the hospital if there was any reason for it or if she had asked. As it turned out, everything went well, but @disneysteve points out, that project management role is very important.

Edit: We rely on our PCP for specialist names, too. All docs are not created equal and his knowledge of who is good, who he has experience with, etc. is one of the things we are paying for.

 

[disneysteve]

project management

That's a great analogy. If you're building a house, you need a floor guy and a cabinet guy and a plumber and an electrician and a roofer, but you also need a coordinator who is at least generally familiar with all of those areas and can help oversee the big picture - and identify problems that might otherwise get missed.

We rely on our PCP for specialist names, too. All docs are not created equal and his knowledge of who is good, who he has experience with, etc. is one of the things we are paying for.

Great point. I was in family practice for 24 years. I definitely knew which specialists I wanted my patients to see, and more importantly which I didn't want them to see.

 

[swakyaby]

^^^^^Glad that worked for you but OTOH, my drug company decided they would no longer pay for a particular drug that I had been taking for over a decade. They said I now needed to take a much less expensive generic, which I knew, and my doctor knew, would not work for me. My PCP argued the case for me but they still said no. So I now pay full price for the brand name out of pocket.

Try looking up your particular brand name prescription on GoodRx, an online discount code that many pharmacies accept. I discovered that when I presented the discount code to my Safeway pharmacy, the price for my new BP medication dropped to half of what I was paying using Blue Shield of California.

 

[OldShooter]

That's a great analogy. If you're building a house, you need a floor guy and a cabinet guy and a plumber and an electrician and a roofer, but you also need a coordinator who is at least generally familiar with all of those areas and can help oversee the big picture - and identify problems that might otherwise get missed.

Thanks, but you're not quite there. Project management is not just an oversight function. When I explain the project manager role to a doc, I say:

"Assume you're in a meeting with the various specialists and there has been a discussion of tradeoffs, options, etc. Then someone says: 'Thank you for all your inputs. This has been a good discussion. Now, here is what we are going to do.' That person is the project manager."
​

Project managers have authority over other participants. Good ones don't have to use that authority very often and can rather guide the process to a good outcome. Consider, too, that the right person to be project manager might be a nurse. IMO it is very hard for many MDs to concede authority, though. Comment, @disneysteve?

 

[Rianne]

We have a PCP and she knows the big picture. I can talk to her about anything and she knows good specialists in our area. We trust her judgment and I communicate with her through the online portal that has all my medical information from 40 years ago. I ask her questions through the portal without a visit. Just completed a complete medical work-up with all the blood tests. I let her know I'm going on medicare.

Although, when I go on medicare this year, I'm going to be thinking about specialists outside of our local healthcare system. Looking to Chicago for better specialists.

 

[swakyaby]

Regarding what happens to coordinated medical care when someone is admitted to the hospital:

At the hospital I used to contract with before retiring, whenever a patient was admitted to the hospital with medical issues, a hospitalist (physician with internal medicine training) was assigned to oversee and coordinate all medical care. Upon discharge, a summary of the patient’s care, including pertinent lab values, diagnoses, any new prescriptions, is sent to the patient’s PCP so that person can be in the loop and pick up the patient’s care after discharge from the hospital.

In the OP’s case, an “intensivist” would be assigned, a cardiologist or pulmonologist with intensive care training to oversee care while in the intensive care unit and provide a succinct summary of care upon discharge to the PCP.

 

[Rianne]

INDENT]"Assume you're in a meeting with the various specialists and there has been a discussion of tradeoffs, options, etc. Then someone says: 'Thank you for all your inputs. This has been a good discussion. Now, here is what we are going to do.' That person is the project manager."

This is the Mayo Clinic group healthcare approach and it saved my brother's life. The specialists worked together and figured out his illness and treatment. He had scattered specialists before and could not get answers or correct diagnoses.

He has a rare autoimmune disease. He would not be with us without the Mayo Clinic groupthink approach to solving medical problems. It was an 8-hour drive for him and several nights in a hotel. Worth it, I'd say.