By William Jantsch MD
I have spent almost 40 years on and off working in Emergency Medicine. Now that I am in the twilight of my career, I have found that I cannot work the overnight shifts in the Emergency Department anymore, so I now staff several Urgent Care clinics in Philadelphia.
The concept of Urgent Care Centers (UCC’s) is very attractive: such a facility is usually open every day for extended hours, and can provide rapid evaluation and treatment of straightforward medical problems for which a primary care doctor is not available. A typical configuration is a doctor and 1-2 medical assistants, and/or a radiology technician who can double as a registrar. Many clinics provide on-site x-ray and rudimentary “portable” bedside testing (called “point of care” testing) for illness such as strep throat, infectious mononucleosis, and influenza.
However, there are limits to the effectiveness of these Urgent Care centers, and these would include:
- No efficient way to set up a patient for an outpatient workup
- The Urgent Care addresses only the immediate problem
- No long-term follow up or evaluation of the efficacy of a treatment
- High costs for minor/trivial medical complaints
Outpatient testing often requires the ordering physician to solicit the approval of a test by the patient’s insurance company (a process called “pre-authorization”). This process can take anywhere from 15 to 45 minutes, and that is time that personnel at a busy clinic do not have to spare. Also, there is no good mechanism for follow up of results of such testing; in most cases, the doctor at the clinic who reads the test results is not the doctor ordering the workup.
If a patient presents to a UCC with a “chronic” complaint (e.g. headaches for a year, 6 months of episodes of upper abdominal pain), the most likely outcome will be that the patient will be advised to seek care from a primary care doctor as soon as possible. This is a real problem for people without insurance who are reluctant to go to a doctor’s office for fear of racking up a big bill. The tragedy is that such an uninsured patient has already been assessed about $150 by the UCC to be told that there is nothing they can do immediately for the problem.
Usually there is a different doctor working in the UCC every day. Therefore, if a patient is seen for a problem one day, and calls back in with a question the next day, there will likely be no one there who has a full recollection of what occurred the previous day. The medical record can provide some information, but in a busy clinic, often times nuanced information is not documented.
The result of such circumstances means that there are many people who present to the UCC who are apt to receive very poor value for the money and time they spend there. This population could be divided into two broad categories: people who do not really need any special treatment anyway, and people with problems that are not in the Urgent Care scope of practice. Examples follow:
- Problems not needing specific treatment:
o Most upper respiratory infections (colds, coughs, bronchitis)
o Most sore throats
o Minor injuries
o Minor abscesses and skin infections (these get better by themselves)
o Many lower urinary tract infections
o Most cases of pediatric fever
- Problems not in the scope of practice in the Urgent Care:
o “chronic” anything
o Abdominal pain
o Menstrual complaints (ongoing pain, bleeding, etc)
o Chest pain evaluation
o Severe infections
o Acute neurological conditions (seizure, stroke, confusion)
o Massive bleeding
Patients with medical conditions in the latter category are “triaged” either to primary care doctors, or to the hospital Emergency Department, where one will find the resources needed for full medical evaluations of complex problems.
Trying to figure out where to get help can be difficult. This is where a medical chat site like BitMED can really be of service. Within just a few minutes of logging on and answering a few questions, you will be able to learn if you need a primary care doctor’s office, a hospital emergency department, or if your problem could be handled definitively in an Urgent Care center.