Editorial

Taking the next step

Copyright © 2010 Society of Hospital Medicine

As resident physicians, we find ourselves at the forefronts of medicine. While tackling the complexities of clinical medicine, all too soon we become entrenched in the bureaucracy of the medical system. We have come to accept realism and practicality over idealism. Shackled by the inefficiencies of a medical system in dire need of reform, we trek forward in hopes of a new future.

I remember the day quite clearly. My 30‐hour shift was nearing an end. It had not been a rough night, but covering both telemetry and coronary care unit services does take a toll on one's physical and mental well‐being. We were ready to discharge Mr. H, an indigent man recovering from a heart attack. I entered his room. He was all dressed. I explained all the important details and handed him a prescription. These medications are very important. Here is a taxi voucher to the pharmacy to get these medications.

He smiled, Thank you very much. You guys saved my life and I really appreciate it.

You are very welcome, I replied. In addition to the medications, it is very important that you follow up with your doctor within 1 to 2 weeks. Do you have any questions?

No problem. You guys saved my life. Thank you so much!

His eyes glistened with tears as he stared right through me, not hearing anything I had said. Mr. H, could you please wait a few more minutes? I will help you schedule a clinic visit.

I quickly located his clinic number at the county hospital. After 3 attempts, I reached a live person. I explained my situation: I am a doctor at a local hospital trying to help a patient setup a clinic appointment. She rattled off a slurry of information, clearly from a script, and left me with 5 different numbers to choose from (the main clinic line, an alternative number, a third number for the urgent advice nurse, one for new patients, and another for subspecialists). The main line was busy, and despite 3 additional attempts, this avenue ended in a recording advising me to leave a message. Unfortunately, my patient lived in an single resident occupancy (SRO) and did not have a phone, and thus leaving a message would not be helpful. I tried another number and the operator informed me that Mr. H was not in the system, and therefore, he would transfer me to the new patients department. The phone rang 5 times before the voicemail message answered, instructing me to leave a detailed message with my contact information. I hung up, and called the original operator back.

I'm sorry. Only the new patient department can schedule appointments for new patients. Here is the direct number. They must be busy. You can try again.

After several attempts, someone answered. My system shows that Mr. H has been assigned to the 7th Street Clinic. He's been seen there before, so you need to contact the main clinic line. I can only make appointments for new patients. She transferred me back to the first operator.

Oh yes, it looks like Mr. H is assigned to 7th Street Clinic. Please hold while I try to locate the next available appointment. He returns 3 minutes later. The next appointment I have is 4 months from now9:30 AM or 3:30 PM?

Is there anyway to schedule an earlier appointment? Mr. H has just recovered from a heart attack and needs to be seen sooner.

I'm sorry. This is the earliest appointment available. If he needs urgent care, he can go to the urgent care clinic Monday through Friday 7:30 AM to 6:00 PM. I persisted and he gave me the clinic's direct line. Sometimes, they may have earlier openings.

I called the 7th Street Clinic. The receptionist informed me that Mr. H was not in the system and she could not help me. I would need to speak with the new patient department. I just spoke with that department, and they were not able to schedule an appointment because their records show he has been seen at 7th Street Clinic in the past.

I'm sorry. He is not in our system. I can't schedule any appointments for him.

Again I went through all the previous numbers and spoke with the same 4 or 5 people, transferring me back and forth through this ridiculous maze, dodging voicemails and busy tones. One hour after I first began this endeavor, I finally succeeded in securing an appointment for Mr. H within 2 weeks as a new patient at a new clinic.

Why had this task been so difficult? Mr. H is the type of individual most at risk of falling through the cracks. Why is it that these individuals, homeless and indigent patients that lack social support, suffering already from countless barriers to health care access and resources because of their socioeconomic status continue to face such a horridly complex system of inefficiency and bureaucracy when trying to make a simple clinic appointment? How difficult and frustrating it was for me to accomplish this taskhow could I expect my patient living in an SRO without a phone to succeed?

Identifying barriers to health care access is the first step in addressing these issues. Previous studies have demonstrated that the majority of barriers to adequate follow‐up after a hospital visit occur among minority groups.17 Lower socioeconomic status is often associated with financial limitations from inability to take time off from work. Among immigrant cohorts, language and cultural barriers also play an important role in affecting follow‐up care. In addition to suboptimal follow‐up care, these barriers often lead to increased patient morbidity and increased rates of hospital readmission. For example, studies have reported that certain minority groups were more likely to receive no pain medication after bone fractures and were less likely to receive adequate analgesia for cancer‐related pain.1, 2, 7 In an attempt to address these issues, several studies have reported on multidisciplinary discharge planning interventions.810 One program in particular involved emergency departments providing free medication, transportation vouchers to and from the patient's primary care clinic, and telephone reminders to schedule follow‐up appointments.10 The implementation of these programs translated into improved primary care follow up, decreased hospital readmission rates, and decreased costs.

It is clear that our current health care system is wrought with inefficiencies that pose significant barriers to access by certain cohorts. The fact that minority groups and cohorts of the lowest socioeconomic status suffer most from these obstacles is concerning. Studies have shown that comprehensive programs to address these barriers including greater access to language interpreters and implementing a multidisciplinary approach to discharge planning improve patient outcomes. As we move forward in the ever‐evolving US medical system, there needs to be greater emphasis on preventative care. Education and resources to improve access to primary care physicians through identification of barriers and developing programs to address these issues is only the first step.

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