Doc in a box

I just made an appointment with one of those free-for-all clinics where you can get into see a doctor immediately, so long as you aren't picky about which doctor. This is all part of my frantic attempt to ready myself for Vietnam: antimalarial meds, ho!

I am solemnly informed that this is not the right way to get medical care; I should have a primary care physician who really knows my case well. But this does not actually describe any primary care physician I have ever had, who was reading off the chart just like a perfect stranger would have. Not only did my physicians clearly recall nothing about me; in many cases, I had to remind them of the details of my chart. So can any of my readers tell me what actual good having a single primary care physician, rather than just any old doctor at a walk-in clinic, makes?

Comments

Wait until you're older, my dear, and have built up a history with a certain doctor. Your nomadic lifestyle isn't helping, to be sure, but even if you manage to settle in one place, you'll need to visit the doc several times over several years for him/her to get some idea of you as you, and not a constellation (small, I hope) of illnesses.

Posted by Mike W | November 6, 2007 3:37 PM

My experience has been different than yours -- my primary care provider has been excellent. In the past year full of medical issue, my primary care doc has often played something of a coordination role between additional providers. I doubt that can happen in a rotating-doctor situation.

More generally, I think the real benefit is that you get to choose your doctor. Whether they remember you might not be terribly important to you, but how good they are probably is. Before I found a doctor I liked, I dealt with urgent care more often, and it was a really mixed bag in terms of overall competence/effectiveness.

Now, if you know what you need (or your needs are generally very clear), this is no big deal. I wouldn't care which doctor signs that antimalarial script. But if I don't know what I need, you better believe that I want the doctor that I think is best to figure it out.

Posted by Brad L | November 6, 2007 3:42 PM

Ask the folks who pay retainers for "concierge doctors".

Posted by Joe Marier | November 6, 2007 3:48 PM

Well I've had two primary care physicians my entire life, before almost a decade of being rationally uninsured. To me one of the benefits was having them understand that I'm intelligent enough to do a pretty good job of self-diagnosing and so many of my later visits were pretty short, basically just the formality involved in getting a prescription.
In fact, my last physician was a refugee from the Canadian system, so we often ended up spending more time bashing it than discussing my ailments.

Posted by Bill Abbott | November 6, 2007 3:53 PM

Willingness to prescribe refills of medicine on short notice without needing to be seen. And depending on your doctor, willingness to prescribe medications without you having to explain to doctors over and over again why you need them (i.e. anti-anxiety drugs or antidepressants).

Also, once you have a primary care physician who is effective, you trust his referrals, negating the need to go the whole "Do you have a good doctor" route with your friends, which can be dicey.

Posted by Catherine | November 6, 2007 4:06 PM

It's good for chronic illnesss management. The frequency of appointments related to the same condition will allow the doc to get familiar with your case and it helps the doc to be familiar with your course of treatment. For a patient with diabetes, for example, working with the same doc over time to manage it would simplify things greatly. For stuff where it will be resolved before you talk to the doctor again, it probably doesn't matter.

Posted by MattXIV | November 6, 2007 4:10 PM

Don't know about primary care so much, but my son has one pediatrician who does remember a great deal about him, and what trends he was having and trying to measure his progress (or he just takes really good notes...lol).

Same with my dentist, though I knew him personally before he became my dentist, so I have perhaps a closer relationship with him than yer average DDS.

I'd also guess in less transient areas than you have lived (NY and DC are not normal...can't emphasize that enough...heh), it is easier to build up a bit of useful context with your primary care physician.

Posted by Kristian | November 6, 2007 4:11 PM

I believe it's easier to get an appointment if you're already an established patient. As Mike W mentioned, I didn't care much about having a specific doctor when I was younger but now I am starting to build up a bit of medical history and it is nice to have a doctor who is familiar with it.

I also have a family and we all share the same PCP, which makes life a bit easier.

Last year my wife came home from work in the morning, suffering from what would turn out to be a badly infected gall bladder. Our doctor could not fit her in until 3 PM but luckily I had a routine checkup scheduled for that day at 11 AM which she was able to swap.

On the gallbladder; she saw the PCP Monday morning, got meds and an appointment for an ultrasound Tuesday AM, ultrasound reviewed by surgeon Tuesday PM who pronounced it "icky looking" and asked her whether she'd like it removed Wednesday AM on an emergency basis, or if she'd like to wait til Thursday AM for a regularly scheduled surgery. Gallbladder came out Thursday and they kept her overnight on IV antibiotics due to some "nasty stuff" leaking out of the gallbladder.

Posted by cdeegan | November 6, 2007 4:29 PM

Echoing earlier commenters, chronic illness management is the principal reason why you want to have a regular doctor. For example, in previous posts, you've mentioned that you had some sort of auto-immune disorder and asthma. A good doctor, one who is familiar with your case history and who is up to speed on developments in medicine, can help tailor treatment regimens (diet, drug, behavioral, etc.) more so than others. As a personal example, my internist told me to stop using Elidel on a regular basis to treat eczema because some doctors recently discovered some correlation between usage of the drug and lymphoma.

In any event, what is probably more important for you is having a regular ob/gyn. My sister, for instance, didn't have one until recently, and she suffered for it when she had mysterious abdominal pains which persisted over several days before disappearing. (The first question her internis--a woman asked--was what does your ob/gyn think?) To the extent that she (or you, if you have such problems) want to have children in the future, the ob/gyn is more likely to be attentive to your problems and needs.

Posted by james h | November 6, 2007 4:34 PM

Personally, I've never had a OB/GYN who was worth a damn (fyi for all you men out there who don't know, Women of childbearing age almost always use an OB as a primary care physician) or who didn't have their own bizarre agenda (The most recent one gave me a 40 minute lecture about how I shouldn't remove my hair...down there...it wasn't natural. I thought it was none of her business how I personally groomed myself and that the next time I wasn't going to bath for a week and that would shut her up on what was "natural or not"), but I know that people who are less healthy than I am often forge great relationships with their doctors and those doctors will help them out ("Dr., I have a sinus infection like the ones I get every 6-8 months, may I have my regular does of antibiotic?"; "Sure!").

I suspect for us it is less important but that as we age it will become more important.

Posted by Kate | November 6, 2007 4:51 PM

I can see three advantages of a consistent doctor:

a. The choice of doctor is nice, because it means that doctors who strike you as incompetent, or rub you the wrong way, or are the wrong gender, or whatever, don't end up being the ones you see. You probably want someone you're pretty comfortable with. (The obvious version of this involves gender, since some people aren't going to be comfortable being examined by someone of the opposite sex. But it's nuts to have a main doctor that you're not comfortable with.)

b. The doctor's office probably keeps records of stuff like previous visits, illnesses, medicines, vaccines, etc. Having all that in one place means you're less likely to get important information lost in the shuffle, especially if you're really ill and aren't up to reminding the doc-in-a-box that you're taking birth control pills and Prozac and Lipitor, broke your collarbone last year, etc.

c. If the doctor remembers seeing you a few times, then he'll have a better idea how to interpret stuff like how you look and sound.

Posted by albatross | November 6, 2007 5:41 PM

My primary doctor knows and remembers me. My family uses a family of dentists (wife does the kids, dad does the adults) and they know us. I'm leary of my wife's OB, but she knows her and has delivered both of our kids.

It's a two-way street... my doctor gets to know me and my health issues and I get to know my doctor and her style.

Also, having a consistent doctor is not enough... you have to find a good doctor to use as your consistent doctor. But one visit isn't enough to know your doctor or vice versa.

EI

Posted by Earnest Iconoclast | November 6, 2007 5:49 PM

Good points about the benefits of having a regular doctor.

But Megan is exactly right about the pointlessness of the medical chart. An MD spends an average of what? -- 8 minutes? -- with each patient. How many of those minutes is he going to spend looking at the chart? I hope my MD has good support staff, 'cuz they're the ones who look over my electronic medical record and find out if I'm allergic to latex, etc. The chart is probably worse than useless: I imagine a doctor could get sued for failing to know the stuff that's on it, yet the doctor really doesn't have (or take?) the time to educate himself.

Doctors are no different than the rest of us. We're awash in information and starved for time to absorb it.

Posted by nobody.really | November 6, 2007 5:49 PM

But Megan is exactly right about the pointlessness of the medical chart. An MD spends an average of what? -- 8 minutes? -- with each patient. How many of those minutes is he going to spend looking at the chart? I hope my MD has good support staff, 'cuz they're the ones who look over my electronic medical record and find out if I'm allergic to latex, etc. The chart is probably worse than useless: I imagine a doctor could get sued for failing to know the stuff that's on it, yet the doctor really doesn't have (or take?) the time to educate himself.

The chart is very important, since for a doc who hasn't treated you before, that's the only source of info beyond your recollection and in an emergency setting, you may not be concious to fill them in. I don't think most docs are going to familiarize themselves with all the old progress notes and lab results absent wanting to find out something in particular about your medical history, but they're definitey going to have a look at your current meds and your allergies (esp if they're going to give you a rx) and your family history if it is relevant to the matter at hand, which is all they'll need to know most of the time and it should be organized well enough that it will only take a few seconds to find that information. Most doctors also spend time between visits or at the end of the day to go over their notes from the visit and the patient's chart to update things.

Posted by MattXIV | November 6, 2007 6:37 PM

Megan, this is important: you do not need antimalarial meds for Vietnam. There is effectively no malaria in Vietnam, apart from occasional cases in remote mountain provinces where you are definitely not going to go. No one in Vietnam takes antimalarial meds; among all the thousands of people I know in Vietnam, over the past several years, I know of not a single case of malaria. Dengue, vicious flus, pneumonia, TB; no malaria. During the Vietnam War, people used to get malaria because they were up in the jungle for months at a time, and for this reason some US docs still seem to think there's a malaria problem here. Malaria has never been common in lowland and urban areas here, and after the war, malaria was eradicated through aggressive insect control and national bed-net programs. It's gone.

If you do get antimalarial meds for some reason, definitely don't take them as prophylaxis. Larium will give you insane dreams. Keep them handy in case you get the disease; artesunate is best. You'll still have the pills when you go home, and you can save them for a trip to Africa.

Posted by brooksfoe | November 6, 2007 8:43 PM

seems that unlike most of the commenters... I have a similar experience to Megan, in that my pri-care doc, hasn't a clue who I am... Even one I went to for 7 years, who did the followup to my anaphalaxsys, had gone to for a lot of the subsequent stuff... yeah. You'd think any doc that pulled your chart and it was actually 2 inch thick charts, would think that just MAYBE there were some issues, and perhaps a cursory glance was in order. But no, I still have to spend 10 minutes hitting the highlights of my health just so I can talk about what is going on now...

If there is anything that is worth something, it is having all the med records in one place, so that if you do indeed need to look back at something yourself, you can go over it, with the doc.

But the truth that one commenter has already alluded to is a big one: There is simply too much info, and too many patients, to remember any one person, UNLESS there is an important reason to. This is why I stick pretty well to my current doc, and tried a change in tack with her. I took an interest in HER life. When she changed her name I joked about her honeymoon, have talked to her about my kids and if she had any and so forth. That seems to have established a relation, where there is more for her memory to fire on. She doesn't remember details, but lots of the trends, and that makes life easier.

Think about it this way, for any of you who do tech support: EVERYONE knows who you are, but there are far too many to remember. The ones you do remember have put additional memories in your head to use... like the lady who used to be a skibum, and has one of those hairless cats... I remember all that because she is lefthanded like me, and has her mouse on the left...

So, the best part about a pricare, is to have the records in one spot. Establishing a relationship with a pricare, is what helps them remember you, out of the thousands they treat...

Posted by D | November 6, 2007 9:06 PM

Funny, that with iPods, USB Drives, et al, peoples still don't have their own copies of their Health Care records that could be provided to any Dr. they saw fit to see. Gee, I mean most of us could store that info on a simple smart card and carry it in our wallets. It just might cut down on the 100,000's of deaths, annually, attributable to our oh-so-costly HC System...to say nothing of speeding check-ins and clueing in busy docs.

Posted by MEH | November 6, 2007 9:32 PM

To MEH: Great point and no joke! I cannot wait until the medical sphere effectively adapts itself to IT. I have lived in four different countries, two socialized, one private (U.S.), and one hybrid, and none did a good job of incorporating latest, basic technology into their system.

McKinsey, the consultancy, did a fascinating study of this in the Netherlands a few years back, and if you look at the savings in both lives and money that could be realized in this regard you would be amazed. Biggest barrier seems to be differing incentives throughout the value chain - even in the U.S., with supposed 'consumer medicine', we are not really in control of our healthcare to the point of being able to demand this as we would of another industry. Sigh, and great to bring up the point since Megan's post is, in part, an allusion to alternative medicine models that may be more prevalent in the future than today.

Posted by Vermando | November 6, 2007 10:10 PM

I'm a medical student now so I've just worked in offices where they had long term patients and clinics where everyone is new. Certainly for young relatively healthy there's not much need to keep the same doctor. But as you get older and you get more chronic and complex problems it can be a much bigger help. As for charts, a lot of the stuff in charts is more for legal protection than communication. Nobody almost ever reads the whole thing, but it can be very useful to look up specific things, like what medicines you're on, were there any changes last time. When were the last vaccines, colonoscopy etc. What was the last blood pressure, blood sugar, cholesterol, weight etc. What meds did we try before that failed etc.It also depends on your perspective of course. Most Americans might not have complex problems that need follow up, but a much larger percentage of patients who actually go to the doctor have complex chronic problems.

Posted by Michael | November 6, 2007 10:19 PM

I am solemnly informed that this is not the right way to get medical care; I should have a primary care physician who really knows my case well.

As you are someone who suffers from a serious chronic condition, and reportedly an autoimmune disorder, you should. Your choice, though.

But this does not actually describe any primary care physician I have ever had, who was reading off the chart just like a perfect stranger would have.

Then you've been seeing the wrong physicians. Never in my life have I had a primary care physician who did NOT know who I was. I cannot recall a single instance when one had to consult the chart for mundane matters while I was in their office. To verify a recollection, or check for blood work results, yes.

Not only did my physicians clearly recall nothing about me; in many cases, I had to remind them of the details of my chart.

Again, you've been seeing the wrong physicians. With your medical history, and your unusual height (which would at minimum be quite memorable), I can't imagine why this is true for you.

If you can't see the benefit of at least having your medical history on file in one place, there is not much I can say to convince you otherwise.

If you are content with the quality of care provided by a "doc-in-a-box," and can't tell the difference, then by all means keep seeing them on an ad-hoc basis. It is your body, so if they screw up treating you because they know nothing about you and will forget you 5 minutes after you leave, that is your problem and you have to live with the consequences. You might demand proof that their malpractice premiums are paid up, however.

Posted by Randy Rogers | November 6, 2007 10:22 PM

as a primary care doc (internist), albeit an academic one, i would echo MikeW; we get to know people we see occasionally over some minimal period of time--longer if the visits are less frequent. We often have to consult the chart because details relevant to a given visit may not have been relevant before.

from other posts i take Megan to be sceptical of the value of physicians individualizing care (rather than relying upon the categorizations of large studies). I think she's mistaken as to the science--as the average effects demonstrated in studies apply to the group, not to the individual, who must be compared by the doc to the group in question; a matter of judgment, not algorithm.

Also, if a doc knows you he/she can inform you better. For relatively simple, self-limited illnesses, docs in the box are fine. But when things get a little more complicated, there are enough imponderables in medicine that the better we know you, the better we can tell you what the options are; that is, tell you in a manner that best accords with what you need to hear.

Posted by Tom | November 6, 2007 11:00 PM

I'm an anesthesiologist, not a primary care physician, so take this with a grain of salt. Experience has shown me that relying on someone's chart is a recipe for disaster - oftentimes, crucial details are missing. So I ask everyone questions that are guaranteed to drive them nuts. I do learn a lot from charts, but they are necessarily incomplete and reflect what the treating doctor thought was important at the time. I would rather hear a story from a person than read it in a chart - not because I'm lazy, but because people often remember details when they tell a story to a person that they forget while writing it down. There's nothing wrong with a doc-in-a-box place, but it's no substitute for long-term followup if that's what you need.

Posted by Devilbunny | November 7, 2007 2:56 AM

I use both. It works great. Why? Doc in the box is there after work, on the weekends, no missed work for some dippy sinus infection that I always get and should! should! be allowed to take care of over the phone with my primary care physician.

(This is a point that should be addressed much more fully, but basically this: for the minor stuff, that I always get, or rather, my wife always gets a cold, followed by a sinus infection. Why for the love of god, can't she call her primary care doctor and say "yeah, you know that CHART you keep? Yeah. Okay, see the previous six years sinus infections? Yeah, nothing else has changed. Yeah, that worked fine last time. Same weight. Yeah. Perfect." But it never works that way.)

The doc in the box is customer friendly and on my insurance: I can take the kids at night or weekends . . . they, wait for it, let me check in on line . . . and call me when its time to come in . . . If you have not experienced this little slice of heaven . . . let me tell you with what jaundiced eye you will look at any doctor from here on out.

And I have a primary care guy too. Great guy. Has all my long term records. I see him once a year for a physical, and for referrals on non emergency items.

Oddly, it works just like a market ought to. One guy for long term needs when scheduling allows, one for the minor junk that happens after work and during life.

The regular doc runs his office based on the model they've all been using since 1903. Good for his schedule mostly good for patients health. Doc in the box hits a twofer.

Posted by TexasPatrick | November 7, 2007 7:32 AM

I don't take my car to any old random mechanic. When I move someplace new, I talk to other people, and shop around. Same thing goes for plumbers, handymen and electricians.

And doctors. I don't take my one and only body to any old random doctor. When I move someplace new, I talk to other people, and shop around.

Posted by ostap | November 7, 2007 8:17 AM

You wrote thit just for the headline, admit it!

Posted by Lane | November 7, 2007 8:31 AM

In addition to all the other reasons mentioned is the fact that it doesn't really matter whether the doctor remembers you or not, because in most gp offices, the nurses (or especially nurse practitioners) will. They are the ones who have the most contact and interaction with the patient, and they usually have a huge impact on your type and quality of care. A majority of daily problems can be narrowed down simply by talking with the patient, and the nps or rns do most of that, except in free clinics where they see so many patients that they have neither the time to talk to, nor the ability to remember, everyone.

Posted by tripp | November 7, 2007 8:54 AM

The one time it mattered, I was 35 and had heart palpitations, which really scared me. I was under stress at the time. I went to my regular doctor and he already had an EKG on me from one of my annual physicals. So, when he did a new one, he had a baseline to compare it to. He always remembered my previous conditions. I think he reviewed my chart before entering the examination room. If a doctor doesn't do that, you need a new doctor.

Posted by John | November 7, 2007 10:14 AM

My initial reaction to the post has been reflected in the comments. There are only two reasons to have a regular doctor: (1) chronic condition, and (2) ageing. For my first 20 years as an adult, I did not have a regular doctor. I was in the military for half that time, and a student and mover-around for the other half.

But as I got older, I started to have some conditions that required a little more regular care. I now have a regular doctor who is quite good, and I CAN call in with a sinus infection and have the prescription called in to the pharmacy. I can also get in on a same-day basis in the event of an emergency. So I've been satisfied, both with the care I received when younger even though I didn't have a regular doctor, and also now that I'm older and do.

Posted by Rex | November 7, 2007 11:01 AM

I work for a wealthy couple who use one of those big-annual-fee concierge doctors, and I can tell you, the advantages are largely administrative--call Monday AM, have an appointment Monday PM -- or the doctor will assure the insurance company a prescription for antibiotic is medically necessary even though you just want it to bring along on vacation "just in case" you get sick and don't know a doctor in Nassau. I'm not sure any of this is beyond what they could get -- for a price-- from any random doctor who doesn't know them though. These are people who pay $1,800 out of pocket for a non-medically-necessary two-block ambulance ride to the emergency room for a non-life-threatening condition because the doc told them if you arrive in an ambulance, the ER staff will see you right away.

Posted by Mrs. H. | November 7, 2007 12:48 PM

A couple of commenters are taken with the idea that a primary care physician will get them a prescription for a sinus infection more easily.

Your doctor may need replacing if he or she will "call in a prescription" for a sinus infection. A real doctor won't, because it's almost always viral, the antibiotics won't do you any good, and exterminating the non-resistant bugs in the vicinity for no particular reason is a bad idea for everyone. (The words you're looking for are "I'll take a swab, and we'll call you if it's bacterial.")

Posted by Radish | November 7, 2007 12:57 PM

There are only two reasons to have a regular doctor: (1) chronic condition, and (2) ageing.

Do you really think so? Based on personal experience, I'm not so sure of that. 44M; no history of heart disease in family tree going back over 4 generations; last routine cholesterol test 185; normal bp 100/60; non-smoker. Visits physician complaining of intermittent pressure on right side extending down arm. In office EKG shows nothing. What are the odds good ol' "Doc-In-The-Box" will say "It's probably indigestion" and send the patient home? Pretty damn good.

But a doctor who knows the patient and knows he doesn't run in willy-nilly for minor aches, pains and sniffles says "I think maybe we should contact a cardiologist." And a couple of days later, after a stress test has to be stopped less than 2:00 minutes after it began because the pressure has reached the wrists and the sensors are recording dangerously erratic goings-on, the cardiologist invites the 44M to have his heart attack in hospital rather than at home, "much more convenient for everyone, especially you" he says with a smile. And he was right.

Posted by RW Rogers | November 7, 2007 2:05 PM

I've used a Doc in the Box for when I was uninsured and needed treatment for strep throat. It was fine for what it was, but I go to a PCP now for all of my non-OB/GYN needs. It's a much better long-term arrangement, for all of the reasons other commenters have mentioned.

My OB/GYN was referred to me by my pediatrician when I was 17 and in need of BC. I've been using the same practice ever since, despite now living quite far away. Now I'm getting flack from friends and co-workers who don't understand why I won't switch to a closer practice, especially as I'm now making the trip every 4 weeks (and soon every 2, and then once-a-week). My answer is that I like this practice, and I'm not trying to expand the number of people familiar with my lady business if it's not necessary.

So let me use this time to lecture you, Megan, about the importance of seeing a gyno every year. And if you are like me, you don't want to be introducing your hoo-ha to a new doctor each time, so find yourself a reputable practice and establish one of the longest relationships you'll ever have.

Posted by Christina | November 7, 2007 2:27 PM

Re: sinus infection -

Good to know that about sinus infections, however I would say that it is important to have them checked out.

I had one, and didn't go immediately, because I don't believe in taking antibiotics unless it is life or death. I think I waited a week, and was keeping other people up with my coughing before I went. The doctor pointed out that the infection could move to my ears if I didn't get it treated.

Posted by Catherine | November 8, 2007 11:06 AM

I'm not sure it's all that helpful to go to a GYN regularly so that you'll be set with an OB when the time comes, because what you want in an OB is so different from what you want in a GYN. How many people ask for a GYN's Ceasarian and episiotomy rates when looking for someone to do their pap smear?

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