Family medicine is in decline

https://thewalrus.ca/your-doctor-wont-see-you/

by mooreds • 2 years ago

88 125 2 years ago

plus2• 2 years ago

I've been experiencing this exact issue in the US. Lately a medical issue of mine has been getting worse, and the earliest I can see a new PCP is in May 2025. I managed to get a referral to a specialist by visiting urgent care, but they referred me to a different specialist, and I won't be able to see the latter until late January 2025. Meanwhile my medical issue is continuing to get worse, and I have no one I can talk to about it. I'm looking into alternative options but things are looking bleak. I'm probably going to have to go out-of-network and drive 2 hours to find a doctor that has wait times on the order of weeks (as opposed to the in-network providers, that have wait times on the order of months).

Spooky23• 2 years ago

I had this issue due the consolidation of medical networks.

Luckily I have a BlueCross PPO. So I’ll get fast access to a specialist in NYC in Boston then transfer the records back to the local dude if needed. My wife had an issue with a complication, and I found a doctor who was a contributor to a major study on it and we got treated by him. Epic makes managing this trivial.

It’s the best of both worlds, but only if you have the privilege of legacy insurance and PTO.

JumpCrisscross9• 2 years ago

I won't be able to see the latter until late January 2025

Where are you? This is unusual.

In America, the "average wait time for a [cardiologist, dermatologist, og/gyn, orthopedic surgery or family medicine] appointment for the 15 large metro markets surveyed in 2022 is 26.0 days" [1]. In Canada, the "median national wait time 1 was 78 days," with wait ime "defined as the period between a patient’s referral by a family physician to a specialist and the visit with said specialist" [2].

Broadly speaking, American medical wait times are quite good, particularly for specialists [3]. But PCPs/capita vary greatly from state to state [4].

[1] https://www.wsha.org/wp-content/uploads/mha2022waittimesurve...

[2] https://pmc.ncbi.nlm.nih.gov/articles/PMC7292524/

[3] https://worldpopulationreview.com/country-rankings/health-ca...

[4] https://www.beckershospitalreview.com/rankings-and-ratings/s...

strict9• 2 years ago

OP is correct in my anecdotal experience. I live in a large urban area and wait time for PCP is several months out. Even longer for Women's health as I hear from my partner.

I don't remember it being this bad in the past. Perhaps things have changed in the several years since those publications were published.

JohnFen2• 2 years ago

This is unusual.

Is it? That's pretty normal in my part of the US, and that's assuming you already have a PCP. If you don't, then finding one that's accepting patients can take much, much longer.

plus2• 2 years ago

Connecticut. Everything is like this here. I have genuinely considered moving because of this. My current employer has another location in California, and as much as I hate the idea of moving back there, it might be necessary for my own physical well-being.

D13Fd• 2 years ago

I've seen this too, in the northeast US. I didn't go to our family doctor of 10+ years for 18 months during COVID-19. When I called for a new appointment, they said I had was no longer a patient and had to wait at least 90 days for an appointment to address a painful condition. I still haven't gone back, and now I just use urgent care if needed.

I had similar problems with a specialist. Their appointments are typically six months out, and if you need something more urgent, the answer is "sorry that's all we can do." My last actual appointment, after the ~six-month wait, was a simple 15-minute telehealth visit. It's insane.

I have great insurance and I've never had any problem paying. It's amazing to me that doctors seem to really push back against having patients, or their patients having appointments. Isn't this how they make money? What kind of weird market effect incentivizes this behavior?

It's interesting that dentists and oral surgeons seem to be the opposite. I've never had a problem finding one and they usually seem welcoming, happy to help, and glad to have the business.

tzs3• 2 years ago

Sometimes a doctor is available but crappy scheduling software hides that.

I got a small scratch from a squirrel and since it did cause a little blood to appear I figured better safe than sorry and went to Kaiser's site to make an appointment with my PCP.

They had nothing for a few weeks.

So I changed to requesting an appointment with any doctor at the same facility. It then gave me an appointment with my PCP for the next day at 9 am.

I've seen similar problems with vaccine scheduling using their web site. It will sometimes only show appointments at a bigger Kaiser facility in the next town, or an even bigger one 30 minutes away.

But if I actually go in and talk to the people at the front desk at the Kaiser office in my town they can often make me an appointment at that facility.

protimewaster2• 2 years ago

I think it's likely simply gotten worse since those studies.

A friend of mine needed a specialist. She called multiple offices across two different states, and the soonest appointment available was about 4 months out.

Four or five years ago, we didn't typically see wait times like that.

BugsJustFindMe• 2 years ago

This is unusual.
In America, the "average wait time for a [cardiologist, dermatologist, og/gyn, orthopedic surgery or family medicine] appointment for the 15 large metro markets surveyed in 2022 is 26.0 days" [1].

I want to point out the important missing fact there that the "America average" time tells you nothing about variance across geography, specialty, or patient population, and you really need to at the very least look further down at the charts where they talk about shortest and longest times in the different cities and specialties.

For instance I see Boston's longest 2022 time for family medicine is 136 days, average 40 days. And Massachusetts is one of the top states on your list for PCPs per capita. At least that's better than 2017 where the longest time was "fuck you, get rekt, lmao".

pton_xd• 2 years ago

In my experience it depends on the speciality you need.

If you need to see an Otolaryngologist (ENT), you might be able to get an appointment within a few weeks. If you need to see an Endocrinologist, it might be 4-6 months.

650REDHAIR• 2 years ago

USA/Bay Area here.

My surgery took months of specialist appointments and months to get an OR slot. There was a conflict and it was delayed again.

I changed networks and when searching for a new PCP I had to wait over a month for the first appointment.

lokar• 2 years ago

IME (SoCal) the 1st visit can take 2-3 months. After that you can get back in with only a 2-3 week wait, shorter if it’s urgent.

They seem to rate limit new patients so current patients can get in.

y-c-o-m-b• 2 years ago

I'm in Oregon - in the Portland metro area - and a cardiologist appointment for me was about 3 months, neurologist about 4 months, and sleep lab 3 months. My PCP is usually a 1-3 weeks wait, but sometimes I get lucky and he's available in like 2 days.

nopinsight• 2 years ago

If you think it’s worth it, you can fly to a few places in East Asia or Southeast Asia where you can see a medical specialist in private hospitals on the same day, especially if arranged a couple of days in advance.

These include Singapore, Thailand, Malaysia, Hong Kong, Taiwan, etc.

The quality of care in these private hospitals is usually high as well.

For some cases, the costs in more affordable locations among the above—even after including economy flights—could be cheaper than treatment in the US.

https://chatgpt.com/share/e/671fb198-2a34-8011-a2e8-e0b4aa45...

nateweiss• 2 years ago

The city of Merida in Mexico might also be an option.

nradov6• 2 years ago

Which metrics are you using to measure quality of care?

31carmichael2• 2 years ago

I visited an international hospital in Saigon to have a skin infection drained and cleaned and bandaged. I remember them charging me around $14. Strange, as surely the nurse used more than $14 in PPE and bandages.

International hospitals in Singapore and Malaysia will be more normally priced, but still a small fraction of what you'd spend in USA.

31carmichael2• 2 years ago

I live in Asia. I can see any specialist within the week, and if it is urgent, possibly that evening. I needed surgery once and they told me to come back at 6pm, the same day.

nsxwolf3• 2 years ago

10 years ago I could see my doctor when I was sick. Like, the same day. Now if it can't be done at the Target or CVS, it's the emergency room. I didn't even get an annual checkup last year because my doctor had to cancel, and the earliest I can be seen again is this summer. I'm now at the age where this is probably starting to matter.

And I pay like... $30,000 a year minimum for this?

bongodongobob2• 2 years ago

I know insurance can be pricey, but $2500/month? Who's your provider? Do you have a family of 6 or something?

elif9• 2 years ago

Premium + deductible + prescriptions + out of network care

I believe 30k is possible for a healthy single American.

nsxwolf3• 2 years ago

Yes, I have a family of 6.

_heimdall3• 2 years ago

I pulled insurance quotes for my wife and I recently. Both of us are young and with no known health issues. Our monthly premiums for the cheapest plan was around $800 per month, but that was with very limited coverage and a deductible of around $15,000 before they would cover any major expenses.

The premiums would be $9,600 a year but all in we could spend around $25,000. We had options for higher premiums and lower deductibles as well, but the total max out of pocket was almost identical.

defen2• 2 years ago

My employer pays $3,575.49 per month for my HDHP ($12,000 deductible). Family of 3. It's Aetna, through one of the large small-business payroll providers. Are we getting ripped off?

JumpCrisscross9• 2 years ago

10 years ago I could see my doctor when I was sick. Like, the same day

Have you tried telemedicine? I've done it through One Medical, and it's a charm for little things that require a quick check-up.

polalavik• 2 years ago

I sort of find telemedicine to a be a scam. I’m sure it has its use case, but most of the time it feels like they are trying to limit liability so they just tell you to go see a doctor in person.

bodiekane• 2 years ago

I'm intrigued by this line from the article:

Before the pandemic, she says, she might have done two disability tax credit forms; last year, she did twenty

Did Covid cause massive disability? Did legislation change to make claiming a disability easier or more lucrative? Are people claiming disability in response to inability to get jobs that meet their expectations?

It's not the point of the article, but a 10x increase in requests for "disability tax credit forms" seems like a very significant sign of something deeply concerning.

I wonder how many people seeking disability are more accurately described as disenfranchised. If people are looking at bleak prospects of low-paid jobs with limited possibilities for advancement, alongside soaring housing and other costs, how many people with previously manageable impairments are throwing in the towel and using a disability designation to escape the rat race.

analyte123• 2 years ago

Even for the first person described in the story, her search for a doctor is not primarily described a search for medical care, but a search for someone who can create a paper trail to ensure her child's eligibility for benefits.

apothegm• 2 years ago

Yes, Covid did cause massive disability. The colloquial term for it is Long Covid. I know at least three people suffering from it —- along a spectrum from slight to severe impairment of daily functioning.

JumpCrisscross9• 2 years ago

Covid did cause massive disability. The colloquial term for it is Long Covid

I know a previously-healthy guy who got an early variant that went for his pancreas. He now has Type 1 diabetes, a condition one is normally born with and for which there is no cure, just chronic, expensive and time-consuming treatment.

RobotToaster• 2 years ago

I think it's a combination of long covid and the effect covid had on people's mental health.

Being "disenfranchised" can very easily lead to major depressive disorder, anxiety disorders, etc.

elif9• 2 years ago

It's so frustrating. We signed up for a pediatric practice in Atlanta that has 8 doctors.

We saw a great doctor on our first visit, then our next visit we didn't even get to see a doctor, just a nurse practitioner... Kinda annoying I don't want parenting advice from a nurse... So on our way out when scheduling we asked if we could see the same Dr next time.

"Oh sorry she only works Tuesdays"

"Okay weird but this is 2 months out though so that should be fine"

"Actually Tuesday would put you over a week away from when the appointment was requested I can schedule you with ..."

3 visits later and we still haven't seen a doctor once. Not even a 30 second pop in the room to say hi.

We've gotten like 20 immunizations from nurses and can't ask doctors about any of it..

Like cool cool all for these peopl advancing their careers without med school but like ... Usually you want your doctor's to have gone through medical school

JumpCrisscross9• 2 years ago

our next visit we didn't even get to see a doctor, just a nurse practitioner... Kinda annoying I don't want parenting advice from a nurse

Is your kid sick? If not, you don't need a doctor.

elif9• 2 years ago

For a baby you have regularly scheduled appointments through the first year to make sure developmental milestones and for the correct immunization schedule.

The amount of bad and actually hazardous parenting advice I've gotten from nurses and PA's is staggering.

When we were discharged from the hospital, the pediatric nurse actually told us it was safe to feed him in the car seat on the drive home.

fma2• 2 years ago

I live in Atlanta and I wonder if it's due to the influx of out of state families moving in. It didn't use to be like this. My child was sick recently and we couldn't get an appointment for a sick visit for several days. This too is an office with a dozen docs/NP.

We ended up going to another one of their offices 30 minutes away which had availability (i.e. lower population density?).

For the receptionist that said "it would put you a week away"...that's when you should just push back and say that's fine. There are very few appointments that need to be exact. And you know what, if you're not sure and you're there, ask the doctor if it's ok :)

Also because I'm trying to spread awareness and you'll likely encounter this: Be aware of "hospital/facility fees".

https://www.theguardian.com/us-news/article/2024/jun/09/pati...

This happened to us, with a Northside Imaging center in a shopping plaza. A chest x-ray that's normally $50 at a regular center is costing us $500.

mg• 2 years ago

I wonder what percentage of medical issues we could tackle by better analyzing and categorizing the existing medical studies that are out there.

And then attaching a user interface to the data that guides the user through a step-by-step self-diagnose process.

bluGill• 2 years ago

There is too much "medical students syndrome" - you learn about some symptoms and they decide you have the issue because the symptoms match even though they don't match in the right way.

There are also a lot of rare things that need expensive procedures that shouldn't be done on a whim. Many medical tests increase your odds of cancer for instance - if you really need that test done to figure out your issue it is worth it, but those tests shouldn't just be done - it is often better to treat the most common causes without verifying that is really the root cause and then only if those treatments fail do the tests to see what you really have.

marcinzm• 2 years ago

This is my understanding of the US situation.

It used to be that doctors were running their own small medical offices a lot. Unfortunately, due to insurance overhead it's no longer profitable for individual doctors to do that, especially without existing patients, so the remaining offices are mostly from doctors near retirement age.

So as doctors retire and new doctors don't want to start their own practices those practices have been getting bought out by large medical networks or private equity. Some offices are also going out of network with insurance companies. It doesn't help that PE is willing to pay a ton more than any new doctor could for the practice.

I'd recommend picking medical plans with out referral requirements and with good out-of-network coverage.

Mistletoe• 2 years ago

My brother was a Family Medicine doctor and he got burned out and retired early and is now a potter lol. His ex gf was a doctor and did the same. I suspect this sort of thing is behind a lot of the issues this article is explaining. After Covid, a large portion of the world that could retire did so and never came back. Those that are left and stuck in that world working or trying to use it, are not happy about it.

CharlieDigital2• 2 years ago

I wrote a more detailed post elsewhere in this thread, but I also think this is the case and you can see an analogue with consolidation of clinical trial sites by private equity.

https://www.fiercebiotech.com/cro/private-equity-invests-tri...

    > Private equity dollars are flowing toward clinical trial sites as industry conditions demand larger site networks, PitchBook's analysis of first quarter 2024 deal activity shows.
    > 
    > For CROs, scooping up trial sites is one aspect of a greater movement toward vertical and horizontal consolidation, a long-standing trend that is still playing out in the space, the PitchBook report confirmed. CROs continue to combine with contract development and manufacturing organizations to establish end-to-end drug development capabilities under a single roof, making them more competitive in the outsourcing market.

eob• 2 years ago

I think Taiwan is worth adding to the list of healthcare systems that folks study. I believe it may be similar to the Swiss system.

Everyone has national health insurance, but you also get to choose where to go, and some doctors also offer non-insured services that you can pay for out of pocket.

The result is universal coverage combined with a competitive market that drives prices down and encourages innovation.

I know this is just anecdata, but having held an insurance card there for a while, our family was always able to see our family doctor the same day we called. And the one or two times a specialist or emergency room was needed, there was minimal hassle.

I'm sure there are problems with it, too -- I just don't know what they are. As a customer/patient, it seemed to work far better than the American system I'm used to.

cameronh90• 2 years ago

Most of Europe has a similar model to what you've described: some form of mandatory state-backed insurance combined with a mix of private and public healthcare providers. In many countries, however, the biggest hospitals in Europe are owned by the government.

Unfortunately the healthcare systems are in the process of collapsing across the UK and the majority of the continent too.

My pet theory is I don't think it's actually anything to do with the overall funding model. I think it's to do with our inability to adapt to an increasingly elderly population. People's kids here are scattered around the country, often many hours of travel away, living in small apartments, and can't easily look after their elderly relatives in a way that's much more common in East Asia. As a consequence, we are offload that responsibility onto the healthcare system, which treats them as patients with medical issues, when often they are just old people with broadly normal age-related disease. Our systems were never designed to be capable of handling millions of elderly people, and it's not an efficient way of providing the required care, so it's falling apart.

aliasxneo• 2 years ago

This is an interesting theory. I just came back from Thailand where I needed to make an ER visit for a grand total of $89 USD, including the price of three prescriptions. I was touring with one of the natives who made a comment around the lines of, "We don't abandon our elderly parents here like you Westerners do." This was in a conversation around their multi-generation households.

It's not necessarily a correlation, but your comment reminded me of the conversation.

FredPret• 2 years ago

A lot of the problems in medical care have nothing to do with the system (Canada vs US) and everything to do with doctor supply.

It’s simply not a great career choice anymore. You start work very late in life, and make only OK money. Some specialists make a lot but they start even later. Some GPs make a lot but they run patient mills. For most GPs, it’s an extreme slog without extreme reward.

The same career issue goes triple for nurses. Young nurses are quitting in droves.

preommr• 2 years ago

It's a broken system. Years of training, very selective, highly expensive... only for a lot of it to be telling people common sense things like eat less and excercise more.

mrguyorama3• 2 years ago

Never mind that half your patients will swear to your face that your entire decade of training was part of a global conspiracy by Bill Gates to put microchips in your arm or other bullshit.

And half of your nurses will agree with them!

Pxtl• 2 years ago

I know it would be political suicide, but I do believe that we could still have a very good medical system if the level of education we demand of doctors was reserved for surgeons and leadership and the front-line work of GP-style treatment was 100% left to people who were qualified by a normal nurse-style process of undergrad + apprenticeship + test.

triceratops• 2 years ago

That's kind of how it works outside of North America. Students go into medical school right out of high school, and medical school is about 6 years - maybe including residency. They graduate with a degree that allows them to practice general and family medicine. If they want to become specialists, they keep studying and more residency.

North America seems to be alone in requiring a 4 year degree before letting a student anywhere near a medical school.

andrewla• 2 years ago

and make only OK money

Sounds like it has a lot to do with the system.

In the US, because of employer insurance, the cost of insurance is mostly hidden from patients. The cost of medical care is similarly opaque -- consumers expect routine checkups to be essentially free, and sick visits to cost next to nothing. Insurance companies are always trying to drive down their costs, and control access for a huge set of patients.

rs999gti• 2 years ago

Why are you using PCPs? The urgent care route seems more efficient, scales, and takes advantage of electronic medical records.

I personally have not had a PCP singular doctor or doctor group in years. I use an urgent care franchise as my PCP.

I have a chronic ailment that requires daily medicine and the medical staff at the urgent care has been more than capable of providing care, writing scripts, and providing referrals to specialists.

CuriouslyC• 2 years ago

Urgent care is often a 1-4 hour wait and insurance tends to have a higher copay. If you have a patient profile at a large health care provider's facility, you can often get appointments same or next day if you're willing to be flexible about the specific provider that sees you, with the normal (~15 minute) wait and lower copay.

squidgedcricket• 2 years ago

Why are you using PCPs?

For primary care. I believe that's where the name Primary Care Provider comes from.

The difference from urgent care is long term. Having the same PCP for long periods of time provides an opportunity for deep insight and developing a personal relationship.

marssaxman• 2 years ago

The idea of an ongoing relationship with a single doctor has always felt to me like a relic of that mythic past when people would spend 40 years working for a single employer before retiring with a pension.

In my life, as a generally healthy person working in the software industry, I have switched health insurance plans almost as many times as I've needed medical attention. What's the point of going through the trouble to establish a relationship with a PCP when you will see them at most twice, likely only once, before you have to start over after taking your next job?

Urgent care is much easier.

lurking_swe• 2 years ago

it sounds like you've never been around old people or an aging parent. When they get old, and start having serious health issues, it’s very important to have a PCP who can play “coach”. They coordinate care with various specialists, and old people typically see many specialists.

You expect an 80 year old to go to urgent care and spent 30 minutes chatting with a random urgent care doctor to get them up to speed on their medical history? lol.

Due to aging population, this PCP shortage is a big problem. Urgent care is fine for a younger person with a simple medical history, or for simple issues.

Aaronstotle• 2 years ago

I want an AI doctor so at least there is some information I can get between the months delay it takes to get an appointment.

jmbwell• 2 years ago

I’ve heard what the article describes about specializing being the way to go. In the US, insurance is also a huge pain in the ass; doctors have to fight to get paid as often as we have to fight to have things covered. There’s also the overhead of insurance for their practice, the costs of running a clinic or being part of a clinic group, maintaining compliance with everything, paying Epic’s extortionate fees, etc.

The last two doctors I’ve had have gone to “concierge” services to help mitigate this. They stabilize their income with annual membership fees that sidestep the insurance company horseshit. They constrain their roster a bit. They can see people more quickly. But you have to be a member.

It’s sad for me, but I get it from their perspective. “Retail” healthcare in the US is by all accounts a nightmare.

the_real_cher• 2 years ago

An interesting thing I'm seeing happening in primary care is that doctors are being replaced by doctor adjacent professions like Nurse Practitioner, Physician Assistant, etc.

A doctor spends a decade working 60 to 80 hour weeks studying medicine whereas an NP is a Master degree, I think which can be obtained online.

There doesn't appear to be clear results yet in studies on the outcomes of NP's vs MD's (see reference).

Another argument is that maybe all that medical school training is overkill in Primary Care and this is perfect setting for NP's or PA's. And also maybe most doctors are not ambitious and forget most of the training they're not using on a daily basis anyway.

I think it would be pretty funny if after more studies NP's showed no different outcomes than MD's.

Interesting write up on NP outcomes.

https://pubmed.ncbi.nlm.nih.gov/18766097/

tomjen3• 2 years ago

If family doctors’ compensation is going to be the lowest of all physicians’, they at least want to rein in their hours and responsibilities. And they want to be able to take a vacation.

The article is relevant, but it is a case of "you get what you pay for".

Empact• 2 years ago

Anyone looking for a solution to physician quality or availability can find it through direct primary care / concierge care. Personally I pay $60/month to have unlimited access to my physician in Austin.

The physician, in turn, rather than having 40% overhead, has no overhead from billing or insurance. They have simple monthly cashflow that they can allocate to cover rent and wages for their practice. This means that the physician can choose how many patients they have relative to their expenses, and decide how much time they have available on average for each patient.

The result is great for the patient, great for the provider, and the sort of thing that will help increase availability of doctors, and their satisfaction with their work.

You can find more on this from https://www.dpcare.org. Here's a map of direct primary care practices: https://mapper.dpcfrontier.com.

fwip2• 2 years ago

Why is this submission flagged?

_heimdall3• 2 years ago

I was wondering the same

monkburger2• 2 years ago

I am a PCP who runs utilization reviews for our provider group. I review every ED utilization for every patient attributed to a PCP in our network. My job is to try to reduce inappropriate ED utilization.

I have no idea what reduces utilization.

There's major shortage of primary care doctors. Most med students don’t want to go into primary care. Plus, hiring new doctors is not as easy as it sounds… even if there were an excess of doctors looking for jobs, you have to have clinic space and staff in order to run a practice.

Specialists are in the same boat, post-COVID. Having to ref some pts to neurology with a 6+ month wait.

dematz• 2 years ago

On replacing doctors with RNs or NPs I think the comment I replied to was removed with mine, so I'll put it here instead. The point is elevating midlevels really is worse care, whereas cutting out years of schooling for doctors would be fine. Again the fact that there's a conflict of interest doesn't falsify these examples - https://old.reddit.com/r/Residency/comments/1geiamv/icu_np_t...

Previous comment:

If you said "Where applicable, level up folks with the desire and aptitude from IT support->senior engineer. This specific pain point is a talent pipeline health and structure challenge. SWE feelings around this are going to be something to consider, to note when preparing for the opposition" people would go wait, maybe the occasional fresh bootcamp grad or ITsupport technician has the potential to do strong work or manage a team, but in general their education has not prepared them. Of course if you ask a doctor "could the RN or NP run this floor" there's a conflict of interest when they tell you "no", but they're also correct.

Having a nurse is probably better than no medical care at all, so a tiered system where poor people get nurses without realizing they're worse than doctors would have that advantage, but the right overhaul imo would be reducing the years of schooling required to become a real doctor (undergrad, med school, residency, maybe fellowship, finally attending). If doctors skipped undergrad and cut out some med school or fellowship requirements, they'd start working earlier and could afford to choose specialties that pay less. As well as expanding residency slots and moving insurance compensation to family medicine and pediatrics.

edit - here's a good example, https://old.reddit.com/r/medicine/comments/1f6m5i9/its_scary... the good news is they'd agree with you that midlevels do have a role, the problem with scope creep is defining what that role is, and the assumption that the training is 80% or even 50% there

washadjeffmad• 2 years ago

Satirist Chris Morris on the state of general practice in the UK:

https://www.youtube.com/watch?v=vECEz1E0HWg

Family medicine is in decline

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