Primary Care fails people surprisingly often.

Patients view doctors as problem-solvers. And this perception works extremely well in doctors’ favor throughout your life. When you’re young, you get sick or hurt. You go to the doctor. They cast your broken arm or prescribe you your bubble gum-flavored amoxicillin and soon you’re all better. From day one, your doctor works miracles. Then you turn 18 or so and graduate from your pediatrician and it’s pretty much the same thing. The issues you face as a 20, 30, and 40-something look more like pediatric issues (sickness and injury) than geriatric issues (cancer and heart disease). Depending on your lifestyle, you don’t start dipping your toe into geriatric-like health issues until you’re in your 50’s and 60’s. That’s when the chronic issues start and doctors start treating you with things that have a NNT of 300, instead of 1 or 2.

You’re so used to doctors fixing you up right quick that these new kinds of drugs for your new chronic diseases don’t seem to be working as quickly as your previous miracle-working doctors. But you still keep the faith because you’ve got decades of miracles under your belt.

But is this true? When you spend time and money on a PCP doctor visit in your pediatric-like phase, what’s the “failure rate?” What percent of the time does your doctor visit not fix your problem? How often does your doctor:

• Do nothing because you just have to wait it out (example: common cold)

• Give you a treatment strategy that doesn’t work (example: a year of allergy shots and your allergies still bother you)

• Refer you to a specialist because they are pressed for time or lack the expertise

• Tell you there’s a 3 week wait for an appointment forcing you to scramble for some other doctor/urgent care

I’m going to broadly generalize here, but here’s a guess:

• Do nothing: 10-15% of the time

• Failed treatment: 10-15% of the time

• Refer you to a specialist: 30% of the time

• Long wait time for “your” PCP: 30%

This means traditional primary care “fails” people in the working age population the vast majority of the time due to the poor design of the service and the limitations of western medicine. Urgent care solved the “long wait time for “your” PCP problem, but at a premium. TelaDoc solved it too, but only for 30 simple things that don’t need much treatment or would resolve on their own by doing nothing.

But, you see that’s the opportunity. We need to reframe the offering of innovative primary care models. It’s a combination of a different promise and a different delivery process.

A different promise

It’s not primarily a place to go to get the quick fix. It’s a place you go to get a guide and advocate who are part of your health issues throughout who just so happen to occasionally quickly fix you. If you say you’re a quick fix and you fail, you lost trust. For example, if primary care can communicate the value of “doing nothing” for your symptoms and humbly state that western medicine doesn’t really have an effective treatment for this, this builds trust. And most importantly, if you can use standardized language with links to trusted online resources, rather than oral conversations via random doctors in 10-minute office visits, people can read, re-read, and learn via videos and other online content. Bronchitis is a perfect example. Here’s what we write to patients with bronchitis:

First, you legitimize their symptoms:

Coughs are annoying and embarrassing. And bronchitis is challenging because you can’t suffer in silence. You are a professional and you’re coughing all the time.

Then you explain what’s normal and what they can expect:

Roughly 100% of people still have a cough six days after developing bronchitis, 50% on day 10, and 10% of people still have a cough 18 days later. Interestingly enough, when people are given antibiotics for bronchitis, you still see coughs in 10% of people on day 18. That means it can seemingly last forever with or without antibiotics.

Then you address myths:

There’s a pervasive cultural belief that bronchitis is cured with a Z-Pack. Cough medicines and other treatments don’t work particularly well, so stressed, busy people become desperate and think antibiotics will be a quick fix. And we as doctors worry about that cough potentially being a pneumonia.

Then you provide scientific reasoning and what to look out for:

Bronchitis (a viral infection) and pneumonia (a bacterial infection) share something in common— a cough. But, in addition to a cough, people with pneumonia develop a fever, shaking chills, a high respiratory rate, and abnormal sounds when a doctor listens to your lungs with a stethoscope. Without these symptoms, I am very confident you do not have a bacterial infection for which antibiotics would be indicated.

And, then you say, if any of these other symptoms develop, just send me a message and I’ll get back to you within 15 minutes. A doctor who is connected to you within 15 minutes throughout all your health issues can practice extremely conservative medicine (markedly reduced antibiotics) because they’ll only prescribe once symptoms are present long enough to reach criteria for an antibiotic-treatable diagnosis. Which leads me to the advantages of a different process.

A different process

If primary care doctors can keep in touch with you online throughout a medical issue and recognize when a treatment strategy isn’t working (instead of only communicating via $150 10-minute office visits every few weeks), this enables doctors to quickly recognize when something is working, change strategies, and ultimately build trust. If primary care didn’t have to only communicate in 10-minute time slots, maybe they wouldn’t be so time-pressed and have to refer you to specialists so much? If communication could happen at any time throughout your medical issues, maybe this would give people comfort that they truly had an advocate working through their issues alongside them? If primary care didn’t operate within 10-minute time slots and worked more like “just in time manufacturing” with 95% of communication and problem-solving conducted via email, the wait time would go from 3 weeks to 15-minute waits to receive a response to your message. If primary care would stop nickel and diming you by adding as many line items as possible to your visit and charge a flat rate to work with you throughout your issues, maybe people would invest in a trusted relationship rather than a quick transaction?