By Sandra G. Boodman OCTOBER 9, 2018
Calvin
Brown doesn’t have a primary care doctor — and the peripatetic 23-year-old
doesn’t want one.
Since
his graduation last year from the University of San Diego, Brown has held a
series of jobs that have taken him to several California cities. “As a young
person in a nomadic state,” Brown said, he prefers finding a walk-in clinic on
the rare occasions when he’s sick.
“The
whole ‘going to the doctor’ phenomenon is something that’s fading away from our
generation,” said Brown, who now lives in Daly City outside San Francisco. “It
means getting in a car [and] going to a waiting room.” In his view, urgent
care, which costs him about $40 per visit, is more convenient — “like
speed dating. Services are rendered in a quick manner.”
Brown’s
views appear to be shared by many millennials, the 83 million Americans born
between 1981 and 1996 who constitute the nation’s biggest generation. Their
preferences — for convenience, fast service, connectivity and price
transparency — are upending the time-honored model of office-based primary
care.
Many
young adults are turning to a fast-growing constellation of alternatives:
retail clinics carved out of drugstores or big-box retail outlets,
free-standing urgent care centers that tout evening and weekend hours, and
online telemedicine sites that offer virtual visits without having to leave
home. Unlike doctors’ offices, where charges are often opaque and disclosed
only after services are rendered, many clinics and telemedicine sites post their
prices.
A national poll of
1,200 randomly selected adults conducted in July by the Kaiser Family
Foundation for this story found that 26 percent said they did not have a
primary care provider. There was a pronounced difference among age groups: 45
percent of 18- to 29-year-olds had no primary care provider, compared with 28
percent of those 30 to 49, 18 percent of those 50 to 64 and 12 percent age 65
and older. (Kaiser Health News is an editorially independent program of the
foundation.)
A 2017 survey by the Employee Benefit
Research Institute, a Washington think tank, and Greenwald and Associates
yielded similar results: 33 percent of millennials did not have a regular
doctor, compared with 15 percent of those age 50 to 64.
“There
is a generational shift,” said Dr. Ateev Mehrotra, an
internist and associate professor in the Department of Health Care Policy at
Harvard Medical School. “These trends are more evident among millennials, but
not unique to them. I think people’s expectations have changed. Convenience [is
prized] in almost every aspect of our lives,” from shopping to online banking.
So is
speed. Younger patients, Mehrotra noted, are unwilling to wait a few days to
see a doctor for an acute problem, a situation that used to be routine. “Now,”
Mehrotra said, “people say, ‘That’s crazy, why would I wait that long?'”
Until
recently, the after-hours alternative to a doctor’s office for treatment of a
strep throat or other acute problem was a hospital emergency room, which
usually meant a long wait and a big bill.
Luring
Millennials
For
decades, primary care physicians have been the doctors with whom patients had
the closest relationship, a bond that can last years. An internist, family
physician, geriatrician or general practitioner traditionally served as a
trusted adviser who coordinated care, ordered tests, helped sort out treatment options
and made referrals to specialists.
But
some experts warn that moving away from a one-on-one relationship may be driving up costs and
worsening the problem of fragmented or unnecessary care, including the misuse
of antibiotics.
A
recent report in JAMA Internal Medicine found that nearly half of patients who
sought treatment at an urgent care clinic for a cold, the flu or a similar
respiratory ailment left with an unnecessary and potentially harmful
prescription for antibiotics, compared with 17 percent of those seen in a
doctor’s office. Antibiotics are useless against viruses and may expose
patients to severe side effects with just a single dose.
“I’ve
seen many people who go to five different places to be treated for a UTI
[urinary tract infection] who don’t have a UTI,” said Dr. Janis Orlowski, a
nephrologist who is chief health care officer at the Association of American
Medical Colleges, or AAMC. “That’s where I see the problem of not having some
kind of continuous care.”
“We all
need care that is coordinated and longitudinal,” said Dr. Michael Munger,
president of the American Academy of Family Physicians, who practices in
Overland Park, Kan. “Regardless of how healthy you are, you need someone who
knows you.” The best time to find that person, Munger and others say, is before
a health crisis, not during one.
And
that may mean waiting weeks. A 2017 survey by
physician search firm Merritt Hawkins found that the average wait time for a
new-patient appointment with a primary care doctor in 15 large metropolitan
areas is 24 days, up from 18.5 days in 2014.
While
wait times for new patients may reflect a shortage of primary care physicians —
in the view of the AAMC — or a maldistribution of doctors,
as other experts argue, there is no dispute that primary care alternatives have
exploded. There are now more than 2,700 retail clinics in the United
States, most in the South and Midwest, according to Rand Corp. researchers.
Connecting
With Care
To
attract and retain patients, especially young adults, primary care practices
are embracing new ways of doing business.
Many
are hiring additional physicians and nurse practitioners to see patients more
quickly. They have rolled out patient portals and other digital tools that
enable people to communicate with their doctors and make appointments via their
smartphones. Some are exploring the use of video visits.
Mott
Blair, a family physician in Wallace, N.C., a rural community 35 miles north of
Wilmington, said he and his partners have made changes to accommodate
millennials, who make up a third of their practice.
“We do
far more messaging and interaction through electronic interface,” he said. “I
think millennials expect that kind of connectivity.” Blair said his practice
has also added same-day appointments.
Although
walk-in clinics may be fine as an option for some illnesses, few are equipped
to provide holistic care, offer knowledgeable referrals to specialists or help
patients decide whether they really need, say, knee surgery, he noted. Primary
care doctors “treat the whole patient. We’re tracking things like: Did you get
your mammogram? Flu shot? Pap smear? Eye exam?”
Dr.
Nitin Damle, an internist and past president of the American College of
Physicians, said that young people develop diabetes, hypertension and other
problems “that require more than one visit.”
“We
know who the best and most appropriate specialists in the area are,” said
Damle, an associate clinical professor of medicine at Brown University in
Providence, R.I. “We know who to go to for asthma, allergies, inflammatory
bowel disease.”
Marquenttha
Purvis, 38, said her primary care doctor was instrumental in helping arrange
treatment for her stage 2 breast cancer last year. “It was important because I
wouldn’t have been able to get the care I needed” without him, said Purvis, who
lives in Richmond, Va.
Sometimes
the fragmented care that can result from not having a doctor has serious
consequences.
Orlowski
cites the case of a relative, a 40-year-old corporate executive with excellent
medical insurance. The man had always been healthy and didn’t think he needed a
primary care physician.
“Between
treating himself and then going to outpatient clinics,” he spent nearly a year
battling a sore throat that turned out to be advanced throat cancer, she said.
For
patients without symptoms or a chronic condition such as asthma or high blood
pressure, a yearly visit to a primary care doctor may not be necessary. Experts
no longer recommend the once-sacrosanct annual physical for
people of all ages.
“Not
all access has to be with you sitting on an exam table,” Munger said. “And I
may not need to see you more than every three years. But I should be that first
point of contact.”
Convenience
Is Paramount
Caitlin
Jozefcyk, 30, a high school history teacher in Sparta, N.J., uses urgent care
when she’s sick. She dumped her primary care doctor seven years ago because
“getting an appointment was so difficult” and he routinely ran 45 minutes
behind schedule. During her recent pregnancy, she saw her obstetrician.
Jozefcyk
knows she’s not building a relationship with a physician — she sees different
doctors at the center — but “really likes the convenience” and extended
hours.
Digital
access is also important to her. “I can make appointments directly through an
app, and prescriptions are sent directly to the pharmacy,” she said.
After
years of going to an urgent care center or, when necessary, an emergency room,
Jessica Luoma, a 29-year-old stay-at-home mother in San Francisco, recently
decided to find a primary care doctor.
“I’m
very healthy, very active,” said Luoma, who has been treated for a kidney
infection and a miscarriage.
Luoma
said her husband pushed her to find a doctor after the insurance offered by his
new employer kicked in.
“He’s a
little more ‘safety first’ than me,” she said. “I figured, ‘Why not?’ — just in
case.”
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