Beep, Beep! Move Over, Primary Care: There’s a New Model in Town

Wallet, check. Keys, check. Phone, check. Beeping, check. Wait, what? What is beeping? I was rushing out the door to a dinner and stopped in my tracks to figure out if the TV was on or the house was on fire. My fiancé, confused, said, “The beeping? Is it … your beeper?” Oh. Yes. The beeping is my beeper. Check.

The primary care physicians (PCPs) at my clinic all have pagers. Mine goes off approximately once every 3 months. Often I forget it’s even there. We have a large practice, and many of us also spend time rounding as academic attendings. We have a call center for after-hours patient calls and an in-house hospitalist to assist with overnight issues when we are on service. However, after-hours communications from other specialists, radiology, or the lab all come to our pagers.

Patient calls are never routed to us after hours. Instead, the triage recommendations include walking in unscheduled the next day, waiting for the primary care team to receive the message and return the call, or going to the emergency department. This last option has become the default for many patients since health care has shifted away from the “dinosaur medicine” model of internists following patients through both inpatient and outpatient episodes. 

This is not a uniquely American problem. The Dutch noticed an increase in emergency room use for nonurgent issues, and they have since piloted a model of “primary care physician cooperatives,” as described in Annals (1). The cooperatives are networks of PCPs embedded in the after-hours triage model. They have PCPs in 3 locations: physically in the emergency departments to manage typical outpatient concerns, on site overseeing their centralized telephone center and answering medical questions by phone, and on call for home visits to address urgent issues. The outcomes are unbelievable: Overall, emergency rooms visits decreased from 13% to 22%. Among patients who self-presented to the emergency room, 75% were treated in the embedded PCP access point.

Physicians and health care systems have multiple methods to address this issue, each requiring variable involvement of a primary care specialist. On the one hand, the PCP could be on call 24/7. This is concierge medicine and requires a certain amount of trust between the patient and provider that this round-the-clock access privilege will not be abused. On the other hand, clinics have central call centers that triage concerns by phone and emergency rooms that triage in person. The PCP is notified after the fact by an electronic alert, if at all. 

Processes like the Netherlands’ approach would be difficult to implement on a national scale in the United States, particularly in the absence of centralized health care system management. However, systems like mine at the VA are already integrated and may be adaptable to this kind of model. Already, I have the ability to do this kind of triage during regular work hours and even have my own urgent care–style treatment room for outpatient management of things like heart failure and COPD.

The question then becomes one of culture. Our office offers “extended hours” until 6 p.m. on Wednesdays and from 8 a.m. to noon on Saturdays, and the teams rotate staffing them every 8 weeks. Colleagues and team members already complain about working nontraditional outpatient times. The Dutch system plans to add a 2-year primary care emergency room training, which would presumably prepare physicians for not only the shift in clinical skills but also the change in sleep schedule.

As much as I like the idea of providing more appropriate primary care throughout the day, I hesitate to suggest shift work. Didn’t we choose primary care because we did not want to work nights anymore, the beep of the alarm at 5 p.m. instead of 5 a.m.? As the current primary care model of after-hours care in the U.S. proves itself unsustainable, I find myself pondering which is the lesser of 2 beepers.

Reference

1. Smits M, Rutten M, Keizer E, Wensing M, Westert G, Giesen P. The development and performance of after-hours primary care in the Netherlands: a narrative review. Ann Intern Med. 2017;166:737-42. [PMID: 28418455] doi:10.7326/M16-2776