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Family physician Pamela Buchanan discusses her article, “The ER doctor who became the new PCP.” In this compelling conversation, Pamela explains her transition from emergency medicine back to primary care, driven by a growing shortage of primary care providers that leaves many patients with no choice but to seek care in the ER. She highlights the strain on both patients and health care workers and emphasizes the importance of prevention and making primary care a more attractive career path for new physicians. Pamela offers actionable takeaways such as advocating for better incentives for primary care, emphasizing early intervention, and reimagining the health care system to support sustainable patient care.
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Transcript
Kevin Pho: Hi and welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome back Pamela Buchanan. She’s a family physician. Today’s KevinMD article is “The ER doctor who became the new PCP.” Pamela, welcome back to the show.
Pamela Buchanan: Hi Kevin, thanks for having me.
Kevin Pho: All right. Tell us what this latest article is about.
Pamela Buchanan: Well, it’s about lived experience and what I’ve been seeing as of late. So, I’m family medicine–trained, but for the last, I think, about 15 years, I’ve been working as an emergency room physician. I left family medicine mostly because of the lifestyle with my children: needing to be home at certain periods of time and not wanting to take work home—especially with all the excessive EMR work. But it’s like I am the new PCP because, by working in the emergency room, I see a lot of patients with primary care–type problems.
I know this has always been true; I remember that from residency on, but it’s becoming even worse. So, it lets me know that a lot of primary care clinicians are quitting and doing other things or decreasing access, so patients are left out in the cold.
Kevin Pho: Now, when you say there are some primary care issues you’re seeing in the emergency department, give some examples of these chronic conditions.
Pamela Buchanan: Oh, well, you see—these chronic conditions are about as American as apple pie. The bread and butter: diabetes, hypertension out of control, of course morbid obesity leading to a lot of other things like osteoarthritis, CHF that’s not managed, coronary heart disease. Those are a lot of things that come from your regular, run-of-the-mill stuff—sniffles, runny nose, vomiting—things that people used to see their primary care for.
Kevin Pho: And are these people coming to the emergency department explicitly because of managing these chronic conditions, or are they coming with something acute and, “Oh, by the way, we have all these other chronic conditions” that are left untreated?
Pamela Buchanan: No, I get a lot of “I can’t find a PCP. I can’t get into the PCP. I used to be on this blood pressure medicine, and I need a refill,” and then the next month, again, again, again—over and over and over.
Kevin Pho: So what options do you have in the emergency department if someone comes in for untreated blood pressure or if they ran out of refills for their diabetes medication? What do you do?
Pamela Buchanan: You know, I used to ask administration that all the time because it’s different. Each doctor does it differently. There are some doctors who, frankly, just don’t treat hypertension in the ER. I have colleagues like that. And there are some who will give you just enough for a couple of weeks. I wonder if that’s even helpful because they’re not going to get into a primary care clinician that quickly.
Generally speaking, it’s up to the physician. My philosophy of practice is: I actually still get on the phone and try and see if there’s a PCP in our area who might be able to fit this person in—if they have insurance. If they don’t have insurance, we’re just in a bad situation. But usually you’re going to get anywhere from no medication to maybe two weeks to a month.
Kevin Pho: And when you get on the phone to try to arrange follow-up primary care, in general, what are the wait times like? Are there even clinicians accepting new patients around your area?
Pamela Buchanan: A lot of closed panels. So, a lot of physicians who don’t have any capacity anymore. And then the wait times—I’ve been seeing, and that’s the reason I wrote this article—the wait times I’ve been seeing are astronomical. I heard one that was a six-month wait for primary care. It used to be this was the kind of wait you only had for specialists.
Kevin Pho: And the fact that these patients are coming to you for chronic conditions—diabetes, high cholesterol, high blood pressure—how does that affect the care you can give to people who really need to be in the emergency department or who come to you in an urgent setting? Are they waiting longer? How does that affect your patient flow?
Pamela Buchanan: It’s bad for everybody in general, and that’s really at the core of why I wrote the article—because it does make the wait time in the ER that much longer. You’d think the ER is for things that are emergent or a person is in imminent danger where their life may hang in the balance, or they need to be hospitalized. That’s really what the ER is for. We have a saying in the ER: “Treat them and street them.” So it’s kind of a different feel when the ER doctor is treating you—that’s not what ER doctors do all the time. They’re not accustomed to managing and adjusting your thyroid medicine or your blood pressure medicine. They’re just accustomed to getting you to the next point, until you can see someone who does this normally.
So yes, the wait times are longer, and it just lets me know that when you support physicians, we cannot afford to lose any more.
Kevin Pho: So in a hypothetical scenario, if someone comes to you with high blood pressure, and you prescribe, say, one month of a blood pressure medication, and they cannot find a primary care clinician, do they end up just coming back to the emergency department after one month?
Pamela Buchanan: Yes, exactly. The very thing I was trying to leave by being a primary care physician is the thing that I am doing now, because there are patients who kind of think of me as their doctor. I was just on shift last night, an overnight, and yeah, it was a patient who said, “Hey, doc,” like I am their doc. I guess I am in some sense, and I know their history at this point. They’re using the ER as primary care—that’s why the ER has become the new primary care for people of low socioeconomic status, for people who have, say, busy jobs where they can’t take the time off. Usually people who work factory-type jobs that are not forgiving if you take off. So we’re just kind of in a situation that’s not ideal and not good for prevention and long-term health management.
Kevin Pho: Just to give us a sense of how prevalent this is, in a typical shift, approximately what percentage of cases that you see are chronic condition–related, primary care–related?
Pamela Buchanan: OK, and I’m not exaggerating, it’s most of what I see. Most of what I’m seeing is just management of chronic conditions and primary care, and probably a third of it are true emergencies and urgent conditions that need hospitalization or some procedure.
Kevin Pho: And is this simply a function of a lack of primary care clinicians? Is that purely the bottleneck—if your local hospitals and medical centers simply increase access, would that solve most of the problems we’re talking about today?
Pamela Buchanan: What I’m hearing from patients is that it’s a combination. Access has decreased sharply, especially since the pandemic. I noticed it wasn’t this bad before the pandemic—it’s always been an issue, but it’s worse now. And so there’s less access. People don’t have insurance. A lot of times, people are having issues with the cost of paying for medications. So I think it’s the combination, but I think one of the biggest problems is access.
Kevin Pho: And just for the patients who may be listening to you now, why is the emergency department not the ideal place to go for follow-up and treatment of chronic conditions?
Pamela Buchanan: Well, because emergency room physicians are more accustomed and better at treating acute care conditions. Chronic conditions are not what they do regularly, and they cannot follow you on a longitudinal basis and manage it effectively. We can’t do labs; we can’t adjust. So it’s just completely not ideal.
Eventually, it becomes a legalistic issue for emergency room physicians. And sometimes it gets to a point where a lot of doctors choose not to continue to prescribe chronic care medications because they can’t be responsible for managing that disease process.
Kevin Pho: So isn’t it a legal liability, too, if someone comes in with high blood pressure, and there is an emergency physician who chooses not to treat their blood pressure or put them on a medication and discharges them? Isn’t that a potential malpractice risk?
Pamela Buchanan: It is, and a lot of ER physicians will treat you while you’re there and give you a follow-up slip, tell you to follow up, but not give a prescription—because, as you know, they’re not going to give you a prescription for six months.
Kevin Pho: How long has this been going on for? You said this was an issue even before the pandemic but acutely worsened after the pandemic. It sounds like it’s been going on for years.
Pamela Buchanan: I don’t remember a time it wasn’t going on, because I started in 2005. I remember it happening here and there. And now that I’m working full-time in the emergency room, it is most of my day—managing some chronic care issue. And yeah, there’s just no capacity. I used to spend a lot of time trying, and most of these people in this community—because I work in a rural hospital—they’ll come back and, de facto, I’m their primary care. But in the ER, I don’t have the time. Yesterday, all day long, every room was full. It’s cold and flu season, the worst time of year in the ER, and so I didn’t have time to manage the disease process. So I just give that Band-Aid prescription.
For most of these people in the community, because I work in a rural hospital, they’ll come back and kind of de facto use me as their primary care. But I feel the obligation to work hard to find them a connection to go to primary care, if not the clinics—there’s usually a clinic or a community health center you can refer someone to. And I educate them that I can’t prescribe this medicine forever.
Kevin Pho: And when you bring these issues up to the health care leaders in your local area or hospital administrators, I’m sure that’s been expressed to them. In general, what have their responses been like?
Pamela Buchanan: I feel like it’s such deaf ears. And that’s what burns me up, because I see that we’re on the precipice of a crisis. There aren’t enough doctors in general, and not enough young doctors are choosing primary care for obvious reasons. And so that’s where we need to figure out a way—we need to give doctors more support. We need to keep more doctors in practice. We cannot all quit. It’s just not good for society.
So when I speak to administration about that, that’s what I speak to them about. I’m passionate that we need to make sure that doctors have good mental health, and make sure that they have coaching and access to various things to keep them healthy mentally and practicing—connecting them back to the why: why they became a doctor. I think injecting a sense of purpose connects you back to why you became a doctor, so you stay fulfilled in your job.
Kevin Pho: What kind of message do you have for patients? Let’s say they’re waiting six months for a primary care physician and they see no recourse but to go to an urgent care or emergency department to get basic chronic care services. Do you have any messages for them in terms of options or tips?
Pamela Buchanan: Well, I do give my patients a spiel that, number one, when you do get a good primary care physician, please let them know you appreciate them, and keep your appointments, because their time is very valuable. Look around in your community, because you have to do some legwork—some hunting—to find out who is taking patients within your insurance. Especially if you have a serious chronic illness, your health depends on it. And sometimes you may have to travel. Sometimes you may have to go 45 minutes out, even an hour out, to be able to get in with primary care. And if it’s only every few months, it’s worth it. So being creative in the solution is what I tell the patients.
Kevin Pho: We’re talking to Pamela Buchanan. She’s a family physician. Today’s KevinMD article is “The ER doctor who became the new PCP.” Pamela, as always, let’s end with some take-home messages that you would like to leave with the KevinMD audience.
Pamela Buchanan: All right. I leave a message that all physicians should take care of themselves. If you’re feeling stressed, that you don’t want to do this anymore, I advise you to seek out a counselor, therapist, or a coach. You can reach me at DrBeStrong.com because I’m committed to keeping more physicians in practice in a healthy way.
Kevin Pho: Pamela, as always, thank you so much for sharing your story, time, and insight, and thanks again for coming back on the show.
Pamela Buchanan: Thank you, Kevin. Have a good one.
