It’s 10:00 pm on Friday night.
You’ve got a bad toothache, and your jaw is swollen and sore to the touch. You’re pretty sure that it’s infected, and it’s getting worse. The pain is really rough. You don’t think you can take it through the night, let alone the whole weekend.
What to do?
You can go to a walk-in clinic, if you live someplace where they stay open after 10:00 pm. But you don’t.
You can go to the Emergency Room at your local hospital, which is always open, and probably wait for 4 hours to get some antibiotics and painkillers.
You can call the “Nurse Line”, but they can’t do anything, and will probably tell you to go to the Emergency Room anyway – you’ve called them before and they usually do.
Or…..if only you could call your doctor, who knows you and knows you’re not a flake. He or she would be able to call in a prescription to the pharmacy 5 blocks away that’s open till midnight.
But your doctor is completely inaccessible.
Your doctor guards his or her personal phone numbers like they were a secret Swiss bank account number.
Your doctor is unavailable out of hours, and the clinic closes at 4:00 pm. If you call the clinic, all you get is a message to go to Emergency.
You feel yourself getting upset, and scared. And peeved.
And then you give up and head off to the ER, with a novel, a water bottle, and a couple of ibuprofen on board.
Research just published by the Rand Corporation shows that in the US, more and more people go to emergency rooms (ER’s) to access basic medical care.
Having worked for 30 years in Canadian ER’s, I can attest that this is true in this country. In fact, Canadians are forced to use emergency rooms for basic care more than in any other industrialized country.
This research makes it clear that an increasingly onerous task is being handed to ER's and ER doctorss around the continent -- that of being an expensive and grossly inefficient substitute for primary care physician accessibility. The spirit of Barbara Starfield, "a famous researcher in the area of what kind of front-line or primary care works best, must be turning over in her grave, in light of this sort of development.
In the long run, this way of accessing care isn’t just frustrating and inefficient.
It’s completely unsustainable. Consider the following: a networked web of primary care practitioners, working singly or in pairs or very small groups (so they can know one another's patients pretty well), who take responsibility for being accessible to and triaging their own patients and initiating investigations and care -- if needed in emergency facilities -- first, before involvement of ER physicians. They leave the ER docs to follow on if, and only if, it is clear that further intensive management is required.
That, in my opinion, is how it used to be. And how it could and should – and one day will be again. I have an old-fashioned but increasingly cutting edge solo practice, in a small town of 17,000. My home phone number is listed in the phone book and is on my business card, which I hand out to any patient who requires information or instructions about care. I take calls any time, but, in practical terms, almost never get a call later than 11:00 pm, or earlier than 7:00 am.