“Is the system supposed to work this way?”

My friend’s husband asked me this question as we stood outside their house in the February cold chatting, while their pajama’d kids ran around inside. His tone was incredulous, his expression both baffled and angry, and his frustration well-justified. I was on my way to go visit her while she was sitting in a local emergency room for the second time in as many days. I had offered to bring her some things from home, like a warm sweatshirt, a book, some decent food… it was going to be a long night for her.

Without divulging identifying details, I can share that she was suffering with a serious orthopedic issue, in great pain, and unable to reach her own doctor. Or rather, her doctor never called her back. Actually, no one from the doctor’s office called her back. She had already endured one long, awful emergency room visit, and had been discharged without an accurate diagnosis nor plan for management, and she had bounced back, still in massive pain. She had reached out to me, and I was trying to help. But I didn’t have any connections at that particular hospital. I’ve left clinical practice and have no healthcare institution affiliation whatsoever. So my attempts to help were limited to bringing her the stuff she needed to be more comfortable, and offering general medical advice, peppered with many caveats.

Like: Here is what I would be thinking if I was still in practice, keeping in mind that I’ve been out for over a year…

And: This is what next steps should look like based on my past experience, though I have no power over this process anymore...

What was fascinating about the entire ordeal was that only two years ago, a different friend– I’ll call her friend #2– had had almost the exact same orthopedic issue and a similar series of ineffective interactions with the healthcare system. She had had no help from her own PCP, sat in an emergency room while suffering with 10/10 pain, waited forever, had inadequate treatment and was discharged without an accurate diagnosis nor plan for management.

In that case, when friend #2 had reached out to me, I had been able to work the system– my system, where I had been practicing for over a decade– to help get her the diagnostic imaging she needed, and then work my connections to get her an urgent surgical consultation.

But that was then, and friend #1’s situation was now. I felt so freaking impotent. And it felt so, so lame to explain to friend #1’s husband that Yeah, the healthcare system as a whole is so poorly organized and dysfunctional that it either requires strong connections or a lucky break to get adequate care.

In the end (and with a little coaching from me) friend #1 was able to advocate for herself. She fended off the ER’s attempt at a second inappropriate discharge, was admitted to the hospital, had the diagnostic imaging she needed, plus an urgent surgical consultation while in-house.

In both cases, it’s true that their own doctor could have helped. It didn’t need to be me, and in fact some may consider my involvement in my friends’ medical care a little ethically borderline. And it’s true: there’s no pre-existing doctor-patient relationship, there are privacy concerns, and there’s also potential for clinical judgment to be clouded by all sorts of socio-emotional factors… it’s a bit of a medicolegal grey area. If I had to defend my involvement in these cases, I’d say: Look, if there’s a fire you could put out, and you’re a firefighter, but you’re not on duty, and you’re not even from that town, and maybe you’re even on vacation… are you seriously going to hesitate? You’re still going to make an effort to put out that fire, right? Even if all you have is a margarita in a plastic cup. C’mon, admit it.

Sure, we could have a little fun debating these cases in a firstyear medical school ethics course, but when the shit hits the fan, if I’m ever languishing in some emergency room and someone I know can step in to help, I’m going to be thankful. I wouldn’t care if it was a friend’s neighbor’s babysitter’s uncle. The emergency room sucks. I’d grab whatever lifeline I could. I would bet that most folks feel that way, which says a lot about our faith in the system.

But what I really wanted to focus on at the outset of this post were the possible reasons for the lack of PCP involvement. These ladies’ own doctors were effectively absent from the whole equation. But why?

The way the system is supposed to work, it’s the PCP’s (or their staff’s) job to at least respond to a call from a patient who is suffering with an acute medical issue. Ideally, they’re supposed to do some preliminary assessment over the phone, and maybe even make few suggestions. This could include providing some education about the suspected underlying medical issue, maybe guide the patient through next steps in management, even if ultimately the patient is better served by going to the emergency room. If that’s the case, the doctor still can answer patient questions and coordinate care, and then maybe follow up afterwards. But, there was none of that here, zero.

I don’t know what happened to these docs, but I do know better than to judge them. Before I walked away from the clinic, it was becoming more and more difficult to be “the way the system is supposed to work” PCP. My panel of active patients was so large (just under a thousand patients!) and my time so crunched (split between patient care, teaching, and research). If I went out of my way for one patient– like, to make the extra phone calls to help them get care in an emergency room somewhere– it took time away from another patient. It was like a big complex game of whacamole except that for every peg I knocked down, two more popped up. I’m very sure that I dropped the ball on several occasions. I know this was a big reason that I quit.

I recently came across a Forbes headline that read “Physicians would need almost 27 hours per day to provide optimal patient care“. It was based on a 2022 study looking at the time required for a primary care doctor to provide guideline-recommended preventative care and chronic disease management, address acute medical issues, as well as complete minimal documentation and respond to inbox messages every workday. The researchers found that a PCP trying to handle all these things on their own would need 27 hours per day — as in, literally more hours than there are in a day– to meet the passing standard. A PCP who was adequately staffed would only need 9 hours per day. (But in reality, it’s rare that a doctor’s office is adequately staffed– mine never was — so it’s safe to say that actual number is a lot higher.) Of course, the study did not take into account all the other stuff doctors have to do, like chasing down radiology reports, reading through specialists’ communications, managing prior authorizations, completing all the hospital’s or the board’s required trainings, or God forbid look at a body fluid sample under the microscope to help make a diagnosis or read up on a patient’s pathology in order to provide better care. And the study most definitely didn’t factor in the above-and-beyond actions that can make all the difference when a patient is languishing in an emergency room somewhere.

No, the system is not supposed to work this way. It was never supposed to work this way. I wish the next part of this post could be a hypothesis or hope for how it can be fixed, but if I had anything to offer I wouldn’t have left.