William E. Jones, MD

A new lady patient was in the office today for a complete physical exam (we'll call her Alice), and her case illustrates perfectly the problem of the fragmentation of health care brought about by low managed care physician fees.
Because doctors are now being paid so little for each office visit, most have no alternative but to rush large numbers of patients through their office every hour leaving them with very little time to spend with each patient. Typically they have barely enough time to address superficially only the one most urgent problem at hand before having to rush on (usually running late already) to the next of the throng of patients crowding their waiting room.

      Alice is 45 years old.    Two months ago she went to her gynecologist's office for a routine pap smear.    As is so often the case these days, she didn't get to see the doctor at all.    Instead her pap smear was done by a Nurse Practitioner (NP).    The NP noted that Alice's blood pressure was a little high; but since gynecologists don't treat hypertension, the NP sent Alice to a cardiologist.    She had to wait several weeks for this appointment.
     The cardiologist agreed that Alice's blood pressure was a little high; so he scheduled her for a physical exam several weeks hence to evaluate the problem further.    When she finally had the physical she mentioned that she'd been feeling a little fatigued; but since her heart checked out OK and cardiologists treat only hearts, she was then "punted" across town to an endocrinologist (hormone specialist) to determine if low thyroid might be the cause of her fatigue.
     After several more weeks of waiting, Alice was finally able to see the endocrinologist.    Blood tests were drawn, and she was asked to return the following week to discuss the results.    At her next appointment the endocrinologist told her that her thyroid had checked out OK.    He suggested that her fatigue might be due to depression; but since endocrinologists don't treat depression, he gave her the name of a psychiatrist.    After all the running around she'd already done, Alice was not a happy camper.

Let's review the hassles this poor lady had to tolerate for two months. She went to the gynecologist only because it was time for her routine annual pap smear, but she ended up seeing a Nurse Practitioner instead of her gynecologist followed by two other specialists (with another referral to a psychiatrist). She had to wait to schedule each doctor appointment, and she then had long waits in each doctor's "waiting" room at each visit. Since specialists these days are so rushed and overworked, they seldom can take the time to communicate with each other about "routine" (non-emergency) matters; so they are often unaware of what other doctors are doing for the patient, i.e., "The left hand doesn't know what the right hand is doing."

Alice is a career woman, and all these doctor visits were costing her a lot of valuable time. Each specialist wanted to be involved only in his/her area of specialization, and each one had to run her in and out of their office as quickly as possible because of low managed care fees; so Alice wasn't getting a chance to have her questions answered; and she felt adrift in a complex health care system in which no one seemed to care about her (or even wanted to talk to her more that briefly). Alice had been "punted" all over town, but she didn't have a sense that any one doctor was actually in charge of all her health care.

Alice shared her frustrations with her friends; and one of them happened to be my patient who suggested that Alice see me. Alice and I spent an hour together during her physical exam today answering all her questions and agreeing on some health goals for her future. She can now have her routine pap smears done here without wasting a lot of valuable time; and I will also be treating her hypertension, keeping tabs on her thyroid, and treating her depression... all in one office. Instead of having to divide her health care between a pot pourri of specialists all over town who each had a narrow interest in only one of Alice's organ systems (but who seemed to have no interest in her as a person), she was delighted to learn that she can now come to one medical office where everyone knows her by name, cares about her, and is enthusiastic about meeting her health needs. Any time she phones she'll be able to talk to a friend she knows and get a same-day appointment when she is ill.
Isn't that the way it ought to be?