Primary care doc - necessary?

[OldShooter]

... 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. ...

In my lexicon, the hospitalist would be "Assistant Program Manager" and his/her authority would be limited to making recommendations to the PCP/Program Manager who actually knows the patient and has history.

DW has a low grade diabetes and one day when she was in the hospital for her hip replacment a guy showed up, doctor or PA I don't remember, and said that based on her blood work he was changing her meds. She objected strenuously and told him that he'd have to get the PCP's approval before he changed a thing. Result was he faded into the woodwork and was never seen or heard from again. Good job DW was the type of person who could and would do this. IMO many wouldn't.

 

[disneysteve]

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?

Ah, sorry if I misunderstood you. Yes, that sounds great. Get input from various people and then formulate a plan based on all of the opinions and options.

 

[disneysteve]

DW has a low grade diabetes and one day when she was in the hospital for her hip replacment a guy showed up, doctor or PA I don't remember, and said that based on her blood work he was changing her meds. She objected strenuously and told him that he'd have to get the PCP's approval before he changed a thing.

This used to drive me crazy. A patient would get admitted for whatever reason and come out days later on a bunch of different meds. Left me to clean up the mess and get them back on the meds that had been working perfectly well for them. And it cost the patient money because they bought the new meds upon discharge only to have me change them back a week or so later.

 

[OldShooter]

Ah, sorry if I misunderstood you. Yes, that sounds great. Get input from various people and then formulate a plan based on all of the opinions and options.

You didn't misunderstand; I just carry the scenario a little further and place significant emphasis on decision-making authority.

Your meds complaint is a poster-child for the absence of project management. In my perfect world your permission would have been sought by whoever wanted to screw around with the existing plan.

Another issue, of course, is how to get paid for the project management role. In my perfect world that is an implementation detail

 

[disneysteve]

Your meds complaint is a poster-child for the absence of project management. In my perfect world your permission would have been sought by whoever wanted to screw around with the existing plan.

Would be nice. I can't tell you how many times a specialist prescribed a medication that was contraindicated due to an unrelated condition or interacted with another medication the patient was taking. Or simply prescribed something that I had already tried that either didn't work or the patient didn't tolerate well.

 

[zinger1457]

I'm assigned a PCP by name but trying to get an appointment with him is very difficult so the doctors office assigns me a nurse practitioner for my checkups. At first I was concerned, thinking I was being shortchanged, but the NP I'm assigned to is very good and organized. I haven't had to see a specialist (except for a dermatologist) in about 15 years, and that was with a different PCP, so not sure how the coordination of care would work out.

 

[OldShooter]

I'm assigned a PCP by name but trying to get an appointment with him is very difficult so the doctors office assigns me a nurse practitioner for my checkups. At first I was concerned, thinking I was being shortchanged, but the NP I'm assigned to is very good and organized. I haven't had to see a specialist (except for a dermatologist) in about 15 years, and that was with a different PCP, so not sure how the coordination of care would work out.

Yeah. All of this thread drift is a bit theoretical given the OP's difficulty in findind a PCP.

In our case we have the luxury of being able to afford a concierge practice, where life is very good. Dr. appointments are scheduled for an hour, for example, and are usually available same-day or next-day if that is what we want. We've never tested it but the enrollment agreement says the docs will make house calls when necessary.

 

[ivinsfan]

This all sounds good in a perfect world. They anecdotal stories from years back don't hold much water any more.



Our main clinic part of large area clinic system. Anything where you need to see a doctor about in the present, go to urgent care. You will not get an appointment with a PCP.



If it's something you can wait on expect to wait weeks for your PCP to have an opening.


When you get to your PCP unless you have a long and extended relationship with them including major medical issues they aren't going to even scan your chart until shortly before they see you.



In a dire emergency such as scuba DH had you get who you get. You won't even get to pick a certain cardio doc. For example DH has heart valve issues so he got assigned a doc who works with lots of valve patients and that can change too. Our clinic now has a dedicated PA for cardio and she does all the "regular" appts. She is the gatekeeper for the actual cardio doc. My DH hasn't seen his actual cardio doc for 3 years.



In an inpatient settings you are going see your doc the day of a surgery and maybe on your discharge day. Otherwise it's a PA your doc uses or the cardio doc of the day on duty. For an extended stay or a complicated stay you will get a hospitalist watching out for things that might fall between the cracks. In hospital your daily RN is your best friend and real gatekeeper.


This all boils down to make sure you know as much as possible about what you have going on medically. Have another person with you that knows everything about your medical history. Listen and ask questions, do not be afraid to speak up. When they talk about contacting your PCP they really mean they will get flagged on the charts. They don't mean literally they will contact them.



From what I have seen in the last 9 years calling a PCP a project manager is overstating what actually happens in todays medical world.



FYI my clinic system is highly rated in a highly rated state. The cardio dept/hosp where DH got his care is one of highest rated in the country. Pretty sure my DH would be dead if he had gotten his care elsewhere.

 

[mystang52]

Echoing other comments, when you have a good PCP, (s)he is invaluable. You need a single manager of your health care.

 

[pacergal]

Yes, you need a PCP--they will overlook everything for you, especially as you start getting referred to other specialists. (at least thats what they are supposed to be doing)
A Primary Care Provider can be a MD, DO, NP, PA.
When we switched insurance, I specifically looked for a younger provider--more up to date training, more likely to be around for us for longer in the group we are in.

Can you contact your insurance for help in finding a provider accepting new patients in your area?

 

[travelover]

Just to add to the yes vote, I had an issue with my eye and I went to three ophthalmologists, each more specialized than the last, culminating with an MRI of my eye area. Then crickets. It was my GP who consulted with me and provided an overall assessment and as well as next steps for my care. It reminded me of working with consultants at MegaCorp. They had all kinds of expert opinions, but in the end never took any long term responsibility.

 

[ivinsfan]

Echoing other comments, when you have a good PCP, (s)he is invaluable. You need a single manager of your health care.

The manager part is where I have the issue. If you work with specialists your pipeline is directly to the specialists. Will you PC be informed of what the specialist is doing yes through electronic charting. That is not the same as managing. After the last 9 years I firmly believe you need to mange your own health care.

 

[gattara]

DH and I had separate primary care doctors, and both retired during the pandemic. We each found young doctors - I chose a female, he chose a male. I was concerned about their inexperience but must say we are pleasantly surprised with the competency of both. It's a big relief! I say try out one of the less experienced doctors, what do you have to lose by meeting with one? If anything out of the ordinary comes up, you'll likely be referred to a specialist.

 

[mf15]

If you need to get supplies from a supplier,such as ostomy bags,and to have Medicare pay. Your PCP has to sign off on it.
oldmike

 

[Katsmeow]

The manager part is where I have the issue. If you work with specialists your pipeline is directly to the specialists. Will you PC be informed of what the specialist is doing yes through electronic charting. That is not the same as managing. After the last 9 years I firmly believe you need to mange your own health care.

I think this is true. I have a PCP who is...OK. He is good when I see him about checking on stuff making sure we are doing recommended screenings. DH used to be a smoker (quit over 35 years ago) so he gets a lung scan periodically. This year the PCP noticed something that indicated DH might have the start of some heart disease and he immediately referred DH to a cardiologist. That was helpful.

One thing that does irritate me is that he doesn't always refer you to the same specialist he referred to before. He recently suggested a specialist for a colonoscopy. It was someone I didn't know and now the same person we had sent DH to. However, he had previously referred me to a gastroenterologist for an endoscopy but didn't suggest him for the colonoscopy even though he does those also. I ended up scheduling with that doctor I already knew. There wasn't anything negative about these doctors. The PCP just didn't look back in my records to see he had already referred me to someone who could also do the colonoscopy.

 

[disneysteve]

If you need to get supplies from a supplier,such as ostomy bags,and to have Medicare pay. Your PCP has to sign off on it.

I don't know why the system is designed that way. So many times I had to sign off on orders for things that I honestly knew nothing about. They were specialty supplies, ordered by a specialist, but I, as the PCP, had to sign the actual orders. Then, of course, when the company had any questions, they contacted me and I usually didn't have a clue how to answer them. I had to reach out to the actual ordering doctor to get the necessary information. It's a huge flaw and inefficiency in the system.

 

[Scuba]

Thanks to all for the responses. The reason I’m hesitant to go to a doctor who is a recent graduate is that our current PCP has decades of experience and is very intuitive. I know from my own career that my judgment of when something was not quite right improved dramatically as I got more experienced. Ideally I would like to find a doc with 10-20 years experience - plenty of time to have developed intuition and diversity of experience, but not old enough to be close to retiring.

It seems that this is not possible in our current location. I have gone onto my insurance company’s website and checked out 50 PCP’s within a reasonable distance (25 miles). I’ve only found two who are accepting new patients and they practice together. They finished their residency programs in 2021.

I also called two different concierge programs. One of them costs $3K/year and there is only one doctor to choose from whose credentials weren’t what I was hoping for. The other costs less and offers 4 docs to choose from, who again don’t have impressive resumes, good online reviews, or much experience. It doesn’t make sense to me to pay extra to see a doc I wouldn’t have chosen based on reviews and credentials/experience.

We can elect to keep our current PCP who is about 2 hours away with light traffic. He can still perform the “overview” function for us, but doesn’t have relationships with any local hospitals since he is so far away.

I’m hoping DH’s cardiologist can refer him to a good PCP. I guess in the meantime he can continue his relationship with his existing PCP who has been treating him for 25 years.

I will likely try the local doc who has been in practice for a year and see how her approach differs from my long-term PCP. I suppose I can keep both for a few years if I choose to as long as I’m willing to cover whatever insurance won’t pay for.

It’s frustrating that finding a PCP is so difficult. I appreciate Freedom 56’s suggestion to use docs in West Los Angeles. I do have one specialist at Cedars, but the drive over there is horrible and my goal is to have a PCP who can oversee my care if I end up in a hospital in the desert. As my DH’s situation proves, hospitalizations aren’t always planned so having a local doc would be nice. DH’s cardiac surgeon wanted to know who DH’s PCP was, and as soon as we told him his PCP was not in the desert, he immediately tuned out and I doubt he contacted him at all while DH was in the hospital.

 

[Scuba]

The manager part is where I have the issue. If you work with specialists your pipeline is directly to the specialists. Will you PC be informed of what the specialist is doing yes through electronic charting. That is not the same as managing. After the last 9 years I firmly believe you need to mange your own health care.

I agree with this. Even though I like my current PCP a lot, the only time he has gotten involved with anything another doc has done is when I have proactively asked him to review my MRI report and give me his opinion on next steps. The rest of the time he receives communication about things I’m having done elsewhere but hasn’t gotten involved. Of course, nothing I’ve had done has been major either.

 

[mf15]

I don't know why the system is designed that way. So many times I had to sign off on orders for things that I honestly knew nothing about. They were specialty supplies, ordered by a specialist, but I, as the PCP, had to sign the actual orders. Then, of course, when the company had any questions, they contacted me and I usually didn't have a clue how to answer them. I had to reach out to the actual ordering doctor to get the necessary information. It's a huge flaw and inefficiency in the system.

For me had to first get off of homecare .
The ostomy nurse was getting the supplies from her supplier. Once off, found my own supplier,then sign up with them,then they sent info to PCP for approval,then to medicare. I suspect perhaps to prevent fraud.

Oldmike

 

[Scuba]

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.

Thanks, yes, DH came home on Tuesday. Long recovery ahead. You are right that the recovery in and of itself feels overwhelming, but even before DH’s emergency, I had wanted to find a local PCP but hadn’t tried very hard yet. With DH resting so much now and me staying home with him instead of my usual busier schedule, I had time to do the research which quickly became disappointing and frustrating.

 

[ivinsfan]

Thanks, yes, DH came home on Tuesday. Long recovery ahead. You are right that the recovery in and of itself feels overwhelming, but even before DH’s emergency, I had wanted to find a local PCP but hadn’t tried very hard yet. With DH resting so much now and me staying home with him instead of my usual busier schedule, I had time to do the research which quickly became disappointing and frustrating.

Very good news..I found that for at least 2 to 3 months minimum afterwards little problems seemed big and bigger problems seemed insurmountable.



It's OK to read a book, watch you tube ( we loved watching Great British bake off together) or clean out your refrigerator while you are both at home together. If possible put off anything more stressful for at least a couple months.

 

[Scuba]

Very good news..I found that for at least 2 to 3 months minimum afterwards little problems seemed big and bigger problems seemed insurmountable.



It's OK to read a book, watch you tube ( we loved watching Great British bake off together) or clean out your refrigerator while you are both at home together. If possible put off anything more stressful for at least a couple months.

Thank you. This is a very stressful situation already so it’s good advice to avoid adding more stress.

 

[OldShooter]

The manager part is where I have the issue. If you work with specialists your pipeline is directly to the specialists. Will you PC be informed of what the specialist is doing yes through electronic charting. That is not the same as managing. After the last 9 years I firmly believe you need to mange your own health care.

I think you're right in most cases. All my blather about project management was about what IMO should be , not what is. @disneysteve is reporting from the battlefront, what is. When the docs are in an environment when they are scheduled for 15 minute patient visits, there really isn't time for a lot of thoughtful project management even if the desire is there. Not inconsequential, too, is that the system probably doesn't pay them for doing this.

So the real world is that we and our spouses have to be the project managers and do the best we can. For DW and me, this includes coaching our concierge PCP towards the project management role, which is out of the norm that he's from.

 

[Freedom56]

Thanks to all for the responses. The reason I’m hesitant to go to a doctor who is a recent graduate is that our current PCP has decades of experience and is very intuitive. I know from my own career that my judgment of when something was not quite right improved dramatically as I got more experienced. Ideally I would like to find a doc with 10-20 years experience - plenty of time to have developed intuition and diversity of experience, but not old enough to be close to retiring.

It seems that this is not possible in our current location. I have gone onto my insurance company’s website and checked out 50 PCP’s within a reasonable distance (25 miles). I’ve only found two who are accepting new patients and they practice together. They finished their residency programs in 2021.

I also called two different concierge programs. One of them costs $3K/year and there is only one doctor to choose from whose credentials weren’t what I was hoping for. The other costs less and offers 4 docs to choose from, who again don’t have impressive resumes, good online reviews, or much experience. It doesn’t make sense to me to pay extra to see a doc I wouldn’t have chosen based on reviews and credentials/experience.

We can elect to keep our current PCP who is about 2 hours away with light traffic. He can still perform the “overview” function for us, but doesn’t have relationships with any local hospitals since he is so far away.

I’m hoping DH’s cardiologist can refer him to a good PCP. I guess in the meantime he can continue his relationship with his existing PCP who has been treating him for 25 years.

I will likely try the local doc who has been in practice for a year and see how her approach differs from my long-term PCP. I suppose I can keep both for a few years if I choose to as long as I’m willing to cover whatever insurance won’t pay for.

It’s frustrating that finding a PCP is so difficult. I appreciate Freedom 56’s suggestion to use docs in West Los Angeles. I do have one specialist at Cedars, but the drive over there is horrible and my goal is to have a PCP who can oversee my care if I end up in a hospital in the desert. As my DH’s situation proves, hospitalizations aren’t always planned so having a local doc would be nice. DH’s cardiac surgeon wanted to know who DH’s PCP was, and as soon as we told him his PCP was not in the desert, he immediately tuned out and I doubt he contacted him at all while DH was in the hospital.

We are not too crazy about driving long distances in traffic to see a doctor and even our dentist is in West Los Angeles, but it made sense for us to seek better quality care given how much we pay for our PPO insurance. In light traffic our drive is about 30-35 minutes so we schedule appointments before or after rush hour traffic.

You may want to consider using the Super Doctors site to find a primary care near you.

https://www.superdoctors.com/

My prior primary care and the current one that I found plus the primary care, and OBGYN that my wife sees at UCLA are "Super Doctors". The chances of finding a good doctor are higher using this site which is free. I ran a search and found only one doctor in our local area and that doctor was with Kaiser which wasn't going to help me.

 

[6miths]

Primary care doctor can be most important member of team. I haven't read entire thread but I am sure many have pointed out that our bias against more recent graduates is unfounded and there is decent evidence that the 'best' doctor is one who graduated 5-10 years ago. Being 'intuitive' is not a particularly good thing in medicine.