“Our proposal is to create a ‘bump list’ made up of patients who call up seeking a same- or next-day appointment.
We have decided to try something new.
Battling between the issues of access, quality of care, continuity of care, and education, we are faced with overwhelming demand for appointments for our patients, and nowhere to put them.
We recently met with our front desk staff, those who answer our phones and try to get appointments for patients, and they tell us that all of the schedules are full for several weeks out.
In a practice such as ours, we know that complete continuity is nearly impossible. Our faculty serve as clinician educators and are spending at least half of their time away from direct patient care, either teaching or supervising residents, and thus have limited availability. And our residents are only in practice for several sessions each week even when they are on ambulatory block rotation, so the ability to get our patients in to see the right doctor at the right time, while critically important, remains maddeningly difficult.
We can agree that seeing your own primary care doctor right when you want to see them is the best solution in most situations. You want to be able to reach your doctor to talk to them when you’re sick, need some medical advice, or have an issue arise that needs evaluating. And most importantly, you want to be able to see your doctor when you’re sick.
We have likely all had the experience of calling a doctor and saying, “I’m sick; I want to be seen” and the office staff saying, “The doctor can see you in 3 weeks.” The old adage in response is, “By then, I’ll either be better, or dead.”
For this and many other reasons, our patients sometimes end up being seen in freestanding urgent care centers, or going to the emergency room for conditions that should be handled in the primary care office.
While these settings are often appropriate (we really don’t want to be seeing anyone having a heart attack or stroke in the outpatient clinic), the vast majority of these could easily be handled in our practice, as a single-problem focused visit.
For the most part, it almost doesn’t matter who you see, as long as they’re trained well enough to be able to handle that particular problem.
Be it strep throat, a rash, a headache, or a sprained ankle, these acute and semi-urgent issues are all well within the purview of primary care practitioners.
And as we’ve seen, our practice battles with a 30% (or higher) no-show rate, so while it may look like there are no available appointments today, without a doubt there’s going to be plenty of times when, spread throughout the practice, there are providers who could be handling these brief, focused visits.
I know, I know — I am always going on and on about how critically important continuity of care is, that the special relationship between a patient and their primary care doctor is the be-all and the end-all. But there is something to be said for learning how to handle interim care, and acute focused visits, that is both educational and satisfying. And there is nothing more “patient-centered” than getting the care you need when you need it.
Our proposal is to create a “bump list” made up of patients who call up seeking a same- or next-day appointment, who are willing to see anybody, and who are willing to accept the rules that their visit is going to be focused on a single issue, along with the caveat that there will definitely be a wait to be seen.
Right now, we have our access team, consisting of one of the residents on ambulatory block rotation and one of our clinical nurses, working as a team triaging all calls coming in with sick complaints, evaluating who needs to be seen today, who they can handle over the phone with some medical advice and suggested treatments, and who should go to the emergency room. And figuring out for whom an appointment can wait until a later date with their primary care doctor.
Over the course of the day, they tell us that the need arises for multiple patients that they would love to get into see somebody, anybody, that day or the next.
In addition, registrars are constantly getting called by people who say they want to be seen today, and we also, despite discouraging this, have a large enough volume of walk-in patients that getting them seen frequently becomes an issue.
Over the course of a practice day, we have anywhere between 15 to 25 residents in practice, as well as a large cadre of attendings seeing patients during their own practice times.
Our proposal is, instead of overbooking patients on the schedule and hoping for no-shows, that we work to ensure that we know who is scheduled to come in to the practice is definitely going to come in, and who’s not coming in is not coming in. Then, we will build patients onto a bump list, and advise them that, for half of them, if they arrive by 8:45 in the morning, they will be seen during our morning practice session, at some point by some provider. And for the other half, if they arrive by 12:45, they will be seen by the end of our afternoon practice by some provider.
Additional restrictions include the fact that they are going to be told in no uncertain terms that the visit is to deal with a single problem. This is not the time or the appointment at which they can raise multiple issues and deal with multiple chronic medical problems. These are designed to be focused visits, one and done, just as you would get in an urgent care center.
The second restriction is, and we think this is crucial, each and every one of those patients must leave the practice with a scheduled future appointment to see their primary care provider.
We are hoping that these appointments, despite intentionally breaking the continuity rule, will help our patients get seen for what they need to be seen, keep them in the healthcare system, keep them out of the emergency room, and ultimately get them back to primary care.
Like all new ideas and experiments, this one is sure to hit some bumps in the road. Already we’ve heard from providers that their practice sessions are far too busy, that patients arrive very late, that no one is going to be able to stay focused on one problem, and so on.
We’re just going to try it and see how it works, and then see if we need to fine-tune it as we go.
No system of scheduling and appointments within internal medicine practices has ever proved to be perfect. But we’ve encountered such a logjam, such an issue here with appointment availability, access, and continuity, that we hope this radical new trial will satisfy our patients, satisfy our learners, and get our patients the care they need.
Fred N. Pelzman, MD, of Weill Cornell Internal Medicine Associates and weekly blogger for MedPage Today, follows what’s going on in the world of primary care medicine. Pelzman’s Picks is a compilation of links to blogs, articles, tweets, journal studies, opinion pieces, and news briefs related to primary care that caught his eye.