Any healthcare system is composed of resources capable of solving problems, like primary care doctor offices, emergency rooms, and specialty hospitals. Here in America, we’re fortunate enough to have the market freedoms to create new, innovative services and see how they fit into today’s landscape of healthcare services. But how capable are these new services and where do they fit on the spectrum of ability to diagnose, treat, and coordinate care effectively?

Tier One: Academic Medical Centers. At the top is obviously the Mass General’s, the Johns Hopkins, the Columbia Presbyterians and their top notch, cutting edge diagnostic and treatment capabilities. It’s obvious here, there’s simply nothing better in resources and capability.

Tier Two: Community hospitals. Although not as capable as large academic medical centers, they are extremely valuable for the majority of medical issues, because the majority of medical issues are bread and butter typical run of the mill problems that need typical solutions by competent local community doctors.

Tier Three: Urgent Care Centers. These are relatively low cost diagnostic and treatment centers for bread and butter acute issues that aren’t going to need hospitalization to solve. These are great. They increase access to medical expertise but aren’t as expensive because they lack the overhead of big hospitals.

Tier Four: Specialist offices. For non-acute issues, specialist offices give people access to highly specialized diagnostic and treatment care for issues that can be treated outside of the hospital via scheduled appointments with specialists in their offices.

Tier Five: Sherpaa. Sherpaa is higher in capability than traditional primary care doctors for a few reasons. First, the combination of phone, messaging, photos and an activity stream of your case allows us to better stay on top of the multitude of updates and evolution of your situation much better than a doctor who’s restricted to communicating with you strictly via a 12 minute office visit. Second, our doctors communicate with you, order tests, get results, diagnose, treat, and prescribe— when they deem appropriate. But when you need to be seen (this happens roughly 30% of the time), we know exactly who you need to see. We make a referral and coordinate your care throughout your next steps with local specialists and facilities. While Sherpaa doctors never see you in person, this is actually a feature, because we don’t have to see you in person to understand that you don’t need our services, you need a specialist or something else higher in capability. So Sherpaa serves not only as primary care doctors but also as care coordinators. We can do this because our communication happens more like email and is presented as an activity stream with status updates, test results, specialist consults arranged in chronological order. Health issues are stories that evolve over time and there is simply no better way to keep up to date and arrange care than this kind of communication. This means every scenario that’s filtered through Sherpaa is the most appropriate use of healthcare. This also means that 70% of traditional primary care visits are unnecessary and do not need to be seen in person.

Tier Six: Office-based Primary care doctors. They are great for in-person meetings for things that require generalist regular in-person physical exams where photos and online communication won’t suffice. They need to see you first to determine that you need something higher in capability leading to marked inefficiencies and expenses in healthcare. The process of primary care is broken, inefficient, and inconvenient and it would serve them well to communicate normally with people rather than restrict themselves to the appointment-driven, 12-minute visits that need to be scheduled 3 or 4 weeks in advance. That kind of communication was invented thousands of years ago and hasn’t been updated. And the business model of primary care means doctors get paid more for doing the most visits. The more you come into the office, the more money they make. This encourages volume and quality is sacrificed. As you can see, today’s version of traditional primary care, if it does not evolve, will be left behind.

Tier Seven: House Call doctor. House call doctors fall victim to the same limitations as traditional primary care visits above. Again, 70% of their visits are unnecessary and should be handled with online communication and photos. But office-based PCPs have access to more tools and tests in their office than what they can carry in a bag and are therefore more capable than house call doctors. House calls are a logistical nightmare and about 30% as efficient as an office-based doctor, making this an irresponsible use of physician time. House calls will never scale and will never be sustainable outside of the market that’s willing to pay $600 out of pocket for a doctor to come to them. 

Tier Eight: Retail health clinics. These are good for simple issues that don’t need a doctor’s expertise and can be diagnosed with conversation, a physical exam, and simple CLIA-waived tests like rapid strep tests. These are issues like pink eye and poison ivy and about 18 others. Because nurse practitioners are restricted in ability and each require physician oversight when diagnosing outside of standard protocols, they are massively restricted in capability. However, because they can see you in person and do tests, nurse-practitioner led retail health clinics are higher in capability than physician video visits who can’t lay hands on you or order tests. Both retail health clinics and physician video visits diagnose and treat the same 20 to 30 simple illnesses begging the question, why are doctors doing a nurse practitioner’s job?

Tier Nine: Physician Video Visit. These are good for the same simple issues as retail health clinics that can be accurately diagnosed with only a conversation and no follow up. Since you’re always talking to a random doctor, they can’t/don’t order tests and follow up to see how the situation evolves and take next steps. Because they can’t physically examine you and order tests, video visits treat the same scope of illnesses that nurse practitioners do in retail health clinics found in your local Walgreens. They are very low in the breadth of problems they solve and, because they face similar 12 minute conversation restrictions, they are communicating and solving problems just as poorly as traditional office-based physicians. All they see is a 12 minute snapshot of a real life story that’s evolving over time and have no way to see if their intervention worked or did not work.

Tier Ten: Nurse triage lines. These increase access to nursing care, but given their issues with liability, their final recommendation is almost always, “it’s best to see your physician about this” leaving you somewhat more knowledgeable about your situation than without the call. However, they are trained professionals and therefore probably better than Dr. Google.

Tier Eleven. Dr. Google. When people have a health issue, the first thing they do is google their symptoms. Some information on the Internet is wonderful. Some is sketchy. And the old cliche is that with everything you google, you end up thinking you have cancer. Online health information works best when it’s filtered with you by a health professional sharing what he/she thinks is most relevant for your case.