I started writing a simple blog about using urgent cares appropriately to get the best care, but I quickly realized that it’s a bigger topic than it first seems. I’ve covered the visit experience itself and the benefits of using your medical home. Now it’s time to talk about the downsides of using an urgent care outside your medical home. Do the downsides of using an outside urgent care outweigh the benefits? Is it worth it to wait for your usual doctor’s office?
Who will you see?
There are many types of independent urgent cares. My community has some that are associated with hospital systems or pharmacies and some that are independent. They are staffed with many different types of providers. Some are even pediatric focused, but others are staffed with people who have little training or experience seeing kids. That means you need to know who you’re seeing and what their background is.
Limited pediatric experience
The provider at the clinic may or may not have adequate training in pediatrics. They often do not have others around who can help if a problem arises that is out of their comfort zone or level of experience and training.
This can lead to over treatment, under recognition of a serious condition, and over testing with unnecessary labs or x-rays.
Simply put, make sure your provider has extensive training in pediatrics.
This is not a “we’re better than you” point.
I do not think that every physician is a good clinician by default. Neither do I think nurse practitioners or physician assistants are not good at what they do. Both physicians as well as NPs and PAs can be great or not so great. We all have our strengths and weaknesses which are built on our interests, training, and experience.
I am getting the following numbers from What Kind of Doctor is Your Doctor? The link includes a nice chart of even more doctor types.
Pediatricians spend at least 3 years during residency learning how to take care of kids. This involves about 2400 hours per year for 3 years taking care of sick kids after medical school. Medical school is about 6000 hours of training. Total clinical training (excluding college years) is a minimum of 13,600 hours. Pediatricians know kids.
Family physicians also spend 3 years in residency after medical school, but that time is not focused on child health. The amount of training caring for children varies based on the program and their experiences.
Physician Assistants spend 2-3 years in a master’s program, with an estimated training time of 2000 hours total. This is not focused on child health at most programs. Much like family physicians, their time is divided between adults and children.
Nurse practitioners spend 1-2 years in a master’s or doctorate program. Clinical training requirements vary from 500-1000 hours. Again, these hours include both adult and pediatric patients. Traditionally most nurse practitioners went into graduate school after many years of nursing experience. That is becoming less common as many are going straight from nursing school into graduate programs, so they do not always have those working years of experience prior to getting their advanced degree.
Years of experience
Of course with all of the training hours, there is also experience after training. You are correct if you say that every person with experience is not better than someone without experience, but in general experience helps.
If a person spends 40+ hours a week for many years taking care of kids, they continue to learn along the way. Sometimes they pick up bad habits, but I can only hope that with experience comes competence. This is best done when people work in a setting that has more experienced colleagues to offer advice along the way, not when they’re thrown into a clinic alone from day one and made to figure it out on their own.
Remember all those clinical hours medical residents spend learning? They are essentially working under those who are more experienced for several years, learning to manage complex (and minor) issues along the way. So even a brand new physician has more experience than some other providers with several years of work experience that may or may not have been supervised.
The risk of getting what you want vs what you need
Most people use walk in clinics for convenience. When their child is sick or injured, they want help ASAP. That’s understandable.
If a baby is crying, the eardrum gets red, but isn’t necessarily infected.
A provider without a lot of experience will often err on calling it an ear infection simply because it’s red. That makes parents happy because they think they’re doing something to make their child better.
They’re not if it’s not a bacterial infection. There’s risk to taking unnecessary medicine.
It’s fastest to write a prescription and move on to the next patient rather than to explain what to do to treat a viral infection.
This is not good care, but it’s common.
Treatments don’t always need a prescription
Don’t feel like you leave empty-handed if you leave the clinic with the information that your child doesn’t need labs or prescription medicine.
Leave with the knowledge of what to do if symptoms change.
Learn how you can help ease symptoms and make them feel better.
You’re not empty-handed – you’re empowered with knowledge!
And then there’s the required surveys…
You have probably been asked to do a survey after shopping. Sometimes you do it for store credit or to help a nice sales person meet their quota.
Sadly, surveys have made their way into healthcare. We can’t offer a discount for your next visit, but many of us are required to collect a certain number of surveys each quarter.
Medical staff are being graded by patients to be sure they’re giving “quality care” ~ and I put that in quotes because I don’t believe that it measures quality at all. I discuss this in more detail in Don’t look for quick fixes for your cold!
Giving a prescription for an antibiotic makes parents happy, regardless if it is necessary. They feel like their trip was worth it because they “got something” to treat the symptoms. This means better satisfaction scores for the clinic because people like to leave with a treatment. It also brings in more money because faster turn around means more patients can be seen. The shorter wait time also drives up satisfaction despite the fact that it’s not good care.
It takes longer to explain how to treat a cold than it does to write a quick script. Parents are generally happy with the visit, but antibiotics are overused and the recommended treatments aren’t adequately discussed. And that’s not okay.
Independent urgent cares do not offer follow-up of issues to see if there is improvement.
Not following up not only prevents assurance that the patient gets appropriate follow-up, but it also keeps the provider from learning how diseases and conditions progress over time. This is one reason why some people with years of experience still tend to over treat or under recognize things.
Stand alone urgent cares do not take phone calls to answer medical questions. They don’t even answer follow-up questions about your visit by phone.
If you have questions, you must call your PCP or return to the urgent care. If we haven’t seen the child for the issue, we are unable to give appropriate advice.
I’ve been asked on many occasions to refill a medication from an urgent care because it was spilled or forgotten on a trip.
I can’t refill a prescription I didn’t write.
The parent can’t call the urgent care provider for a refill because they don’t accept calls.
That’s quite a predicament!
If you require a referral to see a specialist for any reason, it is usually required for your PCP to do that paperwork. There are insurance plans that do not require referrals, and you may schedule on your own unless the specialist requires a referral.
If we haven’t seen your child for the issue at hand, especially if we have no documentation at all about the referral, we often cannot do it without seeing your child.
Why do we need to see your child first?
It is one of the requirements that we must abide by in some of our insurance contracts. Seeing the physician who knows a patient best can help to avoid unnecessary appointments with specialists.
Sometimes it’s as simple as we can’t refer for something we don’t know about. Many referrals require a copy of an office visit.
If we didn’t see your child for a visit, we have no visit supporting the need for the referral. We need documentation to send for the referral.
Sometimes a specialist is not needed
I have seen many situations where an urgent care physician, NP, or PA recommends follow-up with a specialist of some sort that isn’t needed. They often don’t realize that it is quite within the scope of practice of a primary care provider. They cannot know the skill set of every PCP in town. Call your PCP to see if they can handle the issue. It can save you money in lesser copays if you see your PCP first.
An example of this is a concussion. Every provider in my office is competent following most concussions and clearing for play when indicated. Other examples are rashes (including acne), simple fractures and constipation. I’ve seen patients who waited a very long time and paid a lot of money to see specialists for each of these indications based solely on the urgent care recommendation. Most of the time I’m completely unaware of the whole issue until I see them next and they mention seeing the specialist.
They get the same treatment plan at the specialist as we could provide in my office, but at a much higher cost and decreased convenience.
I’ve also seen a number of kids with issues diagnosed at urgent care centers that I disagree with the assessment or plan. This brings us back to all the issues listed above.
One common example of this is a toddler with “recurrent ear infections” who has only had ear infections when seen by an urgent care provider. Every time they see me with the same symptoms, their ears are okay. I often wonder if these kids ever had a real ear infection. Maybe they did and it is simply coincidence, but if they didn’t, they don’t need the risk of anesthesia for tubes. I’d like to have the conversation face to face with the parent after I examine the ears myself.
Continuity of care
There are gaps in care even at urgent cares where there is a pediatrician, nurse practitioner, or physician assistant with extensive pediatric training.
They do not know your child’s full medical background and do not update your child’s health record in the medical home.
Following in one office allows us to see the chronicity or recurrence risk of an issue. If your child goes multiple places for every sore throat, no one recognizes that a tonsillectomy might be beneficial.