2022 was the most frustrating year I’ve ever had.
It was also the year that I learned the most about the US healthcare system.
It began in March, as subtle discomfort appeared on my legs. By July, I experienced a sharp, painful, burning sensation across my arms, back, and legs, similar to a series of bites from fire ants that resulted in welts. It came out of nowhere and persisted—sometimes for days at a time. It would stop for a short while—and ramp up again. The onset was sporadic, unpredictable, and pretty debilitating. The pain made it difficult to focus on work, school, sleep, or social activities. My family saw what it was doing to me, the fatigue, the mood swings, the inability to focus, and they kept asking, “Have you reached out to your doctor?” and “what does your doctor say?”
Reaching out to your doctor—the first step in any medical mystery, but one that, as I have learned, can be easier said than done.
In my case, the first available appointment at my primary care provider’s practice was two months into the future, leaving me to “wait it out.”
Now, I want to acknowledge a few things. During that time, I could have gone to an emergency room or urgent care. As my ailments didn’t appear life-threatening, going to an urgent care or emergency room wasn’t worth the waiting time or costs to (almost certainly) be told, “You need to follow up and make an appointment with your primary care physician.”
So, I waited. I waited and I did my homework. I reached out to five specialists. This meant not only identifying specialists in this area, but also finding those who both were open to new patients and took my insurance. Some had a six-month waiting list for new patients. Eventually, I got an appointment with one: in another city over an hour away. I remain grateful to the practice manager who juggled the practice schedule to find me time. That meeting led to a referral for a second opinion, the mystery’s resolution, and a tentative diagnosis: cholinergic urticaria—or, as the physician explained, “rashes with a hint of evil.”
While I still don’t know what caused the “evil rashes.” Was it an allergic reaction? Temperature changes? Stress? While it was a huge relief to “solve” my health mystery, the experience made me think about our healthcare system and the accessibility of primary care health services.
One question kept returning to my mind: why was it so difficult to get an appointment with a primary care provider? What does that say about our healthcare system?
Shortages & Burnout in Primary Care
Primary care is often cited as the foundation of patient-centred healthcare delivery. However, across the United States, there’s a delay in receiving timely, quality care from our primary care providers. This is particularly acute in underserved areas or where there is a physician shortage. As this is a growing problem, accelerated by the stressors of the pandemic, two immediate factors have to be considered: provider shortages and provider burnout.
Burnout and staff shortages were a critical issue before the COVID-19 pandemic, but have significantly risen following the public health crisis. Illustrated by a survey conducted by the Commonwealth Fund of Primary Care Physicians, physicians across 10 high-income countries reported a significant increase in workload and increased emotional distress and burnout. Younger physicians were more likely to report emotional distress and burnout compared to older colleagues (55 and older). Older colleagues reported planning to stop seeing patients in the near future, many accelerating plans to retire.
The “exiting” of older physicians presents a real problem to a challenging workforce pipeline. The loss of these experienced physicians compounds the time needed to train new medical workers. The stress is already present in younger physicians—so imagine how it will be when the majority of the preceding generation is gone. The only ones left are those already bearing burnout and emotional tolls.
Although we can’t underestimate the impact of burnout across a profession. In our November 2022’s Founder’s Letter, Michealle Gady identified burnout is the key driver of the rising healthcare crisis. The environments and conditions in which providers practice are changing—generally not for the better. Failing to address the inadequacies of the environments and conditions that providers operate in (which includes having to manage increased workloads while understaffed) means that the cycle burns through more and more providers.
The impact of provider shortages has been most visible as it relates to hospitals.
Amy Foster, the Vice President for Quality & Patient Safety with the American Hospital Association, spoke with CNN about this issue, stating that the workforce shortages have made it challenging to provide care for those who desperately need it. “[Thus], patients are spending more time in hospitals, awaiting discharge to the next level of care and limiting our ability to make a bed available to a patient who truly needs to be hospitalized.”
Putting it in Perspective
With that background, let’s return to my own experience. I live in Wilmington, North Carolina. It’s a medium-sized city in New Hanover County, with at least two hospitals in a thirty-mile radius. This means I (theoretically) have decent access to a spread of providers. Of course, there is a gap between theory and practice, when you factor in the realities of insurance networks and closed patient panels (where a provider no longer accepts new patients). Even though the options are there, and usually within an hour or two’s travel.
That is not the case for many Americans, particularly those living in more rural areas, which commonly lack the resources and infrastructure of urban and suburban areas. Living in these areas, there is less of a gap between “theory and practice”—the unavailability of primary care providers is just a reality. In the United States, over 60 million Americans live in federally designated primary care health provider shortage areas—the majority of those are in rural communities.
Let us also keep in mind the logistics that go into accessing available healthcare services: adequate insurance, the ability to meet the cost of co-pays, transportation, the ability to take time off work. These are not minor details, as I came to appreciate in my own experience. An appointment that drains two to three hours I usually dedicate to work (the average time it takes a patient in an urban area to complete a healthcare appointment), is much different from an appointment that drains six hours, or eight, or ten. A whole day of possible income lost weighed against possible treatment or possible disappointment. These are real barriers, particularly for anyone who does not have a flexible work schedule, lacks transportation, or has other commitments like childcare and caretaking of other family members. Is it any wonder that many delay care?
So Now What?
The most important lesson that I took away from my experience was that availability of health care services isn’t the same as access. Even with insurance, and living in a more affluent area where there is adequate health infrastructure (as I do) it is not an easy thing to get a timely appointment with a primary care provider. Let’s be clear, it took nine months to get an idea of what the rashes of a touch of evil was, but no idea how or why. I still have a lot of appointments and research to do. Furthermore, navigating the system as a patient, particularly when your symptoms fall outside of the “usual presentation” is challenging, frustrating, and time-consuming.
To repeat: availability is not the same thing as accessibility. However, we also have a problem with the availability of basic primary healthcare services. I see this within my own community, and know that it is even more pronounced across my region. As it stands, we face a shortage of offices, providers, and services that the public depends on, whether in rural Nebraska or urban North Carolina. Provider burnout, driven by not only the demands and fall-out of the pandemic, but also the changing conditions and structure of healthcare, are a primary factor in this crisis.
Addressing immediate provider burnout and shortages is just the beginning and the issue won’t solve itself. Nothing can be resolved unless and until we recognize that there is a problem that requires urgent action. My experience in navigating my care this past year provided me with a tiny, tiny keyhole view into a bigger problem. It is something that I would encourage all of us to pay closer attention to. When we think about health care crises and shortages we generally think about the availability of emergency care and hospital beds.
These are critical components of our healthcare infrastructure, but they aren’t the only thing that matters when it comes to insuring quality healthcare: the accessibility of primary care matters as well, particularly as we have based so much of our reform efforts around primary care. So, I close by reflecting on the observation that I opened with: it is a little crazy that it took two months to get an appointment with my primary care provider—and what does that say about our healthcare system today? We need to listen to these data points.
