The Trickle-Down Effect of Undervaluing Our Healthcare Providers

• Obtaining follow-up appointments after a hospital discharge can be difficult — and a result of issues that plague healthcare providers. 
• Among the catalysts for these struggles are increased specialization among practitioners and a decrease in primary care providers. 
• A stressed system is not a sustainable system and though a solution is murky, it’s abundantly clear that we need one, and fast.  

A Healthcare Providers Scenario

I start my day as a provider on the hospital medicine team and receive my assignment or “list” of patients for the day. Based on the brief summary provided by the prior provider, I make a quick note of who might be ready for discharge and who likely is not.  

I see on my list a 66-year-old female with right lower extremity pain with a history of diabetes and hypertension. My eyes fixate on her profile. She seems too young to be in the hospital, and too sick for her age. She initially presented to the emergency room for evaluation of worsening right lower extremity pain that started in her back and began radiating down her leg. She had several comorbidities that were concerning, including poorly controlled diabetes and poorly controlled hypertension.  

Upon meeting her, she explained that she had already been to another hospital for evaluation of the same problem. They had performed a test to rule out a clot in her leg (the test was negative), and she was told to follow up with her primary care provider (PCP). She told to her current PCP had retired, she recently moved to her daughter’s house in a different town, and that she was currently searching for a new provider. Multiple variables in this story concerned me.  

Firstly, her presenting problem seemed like it could have been managed as an outpatient. Why was this not the case here?  Secondly, her comorbidities were more concerning than her presenting problem in my eyes; she required specialized follow-up in addition to a new PCP.  

Hospital care requires a vast knowledge of medicine, but it also requires the ability to focus on the primary problem. The primary goal of a hospital stay is to treat the presenting problem, provide adequate support on discharge, and appropriate follow up in the outpatient world. 

The outpatient follow-up visit is meant to continue the interventions that were initiated in the hospital and ensure that any necessary further management occurs. When a patient doesn’t have the proper outpatient providers in place, the discharge process can become tricky. Particularly for this patient, I was concerned that her comorbidities were going so unchecked that she was at risk for far greater complications than lower extremity discomfort. 

The Healthcare Providers Problem

In the acute care setting, we use case managers who are registered nurses (RNs). They are tasked with coordinating the logistics of the discharge plan, including arranging visiting nurse services (as well as physical therapists, occupational therapists) and PCP appointments. They are integral in ensuring patients receive the necessary care once discharged.  

In my experience, (after discussing at length with case managers and patients) primary care appointments are very hard to come by. It seems that there just aren’t enough providers for the number of patients who need to be seen.  

While medical schools continue to be densely attended, with each newly minted physician, the number of primary care physicians is actually dwindling. Doctors are not choosing primary care as their area of practice; they are choosing specialty practice more and more. The Commonwealth Fund found that poor financial gain for physicians specializing in primary care is a driving factor. Additionally, advanced practice providers, nurse practitioners and physician assistants, are also trending toward specialty practice, according to a CBS News report.  

This access challenge leads to over-utilization of emergency services (ER) in lieu of primary care. Exploitation of ERs strains the healthcare system because it wasn’t designed to withstand this level of utilization. Simply put, this is not how the system is supposed to work. The increased stress on the system results in burnout of each professional in the chain (doctors, advanced practice providers, nurses, nursing assistants, phlebotomists, radiology technicians, etc.).   

When we don’t have enough primary care providers, patients will continue to rely on emergency services for their care. Unfortunately, this sets off a self-perpetuating cycle: patient sees provider in ER, patient is treated, patient is discharged with no appropriate provider to follow up with, patient’s problem is not fully improved, patient returns to ER. And thus, the cycle repeats itself, worsening the already stressed system and all of its members. 

The Bottom Line

I’m not sure there is a simple answer. Perhaps if we place more value on our primary care providers more people will be inclined to choose that line of work. A stressed system is not sustainable. And though a solution is murky, it’s abundantly clear that we need one, and fast. 

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