Introducing "Pulse Check": Your health questions answered

Today's installment: Why is there so much confusion over Urgent Cares?

Hello readers! I’m adding a new feature to my substack called “Pulse Check,” your bi-monthly guide through the labyrinth of health and healthcare. “Pulse Check” is inspired by the questions I field from friends and family – and now, you! This series aims to expand your healthspan, enhance health literacy and demystify the healthcare system through an exploration of science and evidence-based medicine. We’ll tackle your pressing questions: Whether it’s understanding the best way to prevent traveler’s diarrhea, how to make the most out of a 15 minute doctor’s visit, or what to do when you get a new cancer diagnosis, “Pulse Check” is here. Let’s unravel the complexities of healthcare so you can make better, cheaper, and less infuriating healthcare choices. No question is too simple, too complex, or too odd. This series is fueled by your curiosity and concerns. So leave your questions in the comments section!

Today’s installment: Why is there so much confusion over Urgent Cares?

A mother once brought her healthy five-year-old into the ER by ambulance for a paper cut. This is not a joke. The kid with a papercut might be an extreme example, but the number of times a patient has rolled into the ER with a bruise, or on day five of a cold they “really need to get rid of,” and I’ve thought, “Don’t you know this is an emergency room? For emergencies?” are too numerous to count. I don’t say it aloud, though, because I like being employed, and because the surface reason someone shows up to an ER frequently isn’t the real reason. Maybe they’re freezing or lonely or the bruise or the cold or the papercut seemed like an emergency in the moment, a feeling with which I can sympathize, having questioned my own existential place in the universe after almost a week of having both nostrils completely plugged secondary to rhinovirus.[1] The bruise or the cold or the paper cut probably felt like less of an emergency after sitting in the ER for eight hours to get some skin glue, or a pity prescription for Mucinex and Sudafed, and a $5k bill. Out-of-pocket costs for insurance are high these days! That’s good from a public-policy perspective but not great for people who come to the ER without truly needing the ER. Extreme chest pain? Come in. Ennui? There are less pricey options.    

Maybe it’s bad for my patient satisfaction scores, but I like to ask people who’ve come to the ER for what seem like minor complaints why they chose to come to an emergency room, and I often hear, “I wasn’t sure who would be able to take care of the problem, and I figured you guys could take care of everything.” I enjoy the implication that we’re like a Wal-Mart supercenter. I ask in a spirit of open curiosity, not because I’m trying to be a jerk,[2]  but because something is broken in a system where the most expensive choice becomes a default. Understanding how people navigate a moderately broken system helps me to understand the system (that impetus led me, for example, to write an essay-guide about how the clinical-trial system works). The patients are also right: the ER is always available, which is unique in healthcare. The ER is a bit like Vegas: we never close, we’re frequently windowless, there aren’t many clocks, the lights are fluorescent, and there’s always someone who’s loud and drunk—but going to the least-appropriate facility wastes money and time.

I thought of those patients while reading “How to Know Whether to Go to Your Doctor, or Visit Urgent Care: Relying too much on urgent care for treatment might mean you miss bigger health issues” (wsj, $), which discusses what you’d expect from the title. I’m not bringing it up here because it’s an impressive, unique piece of journalism; it’s another bit of healthcare info fluff. But it and similar articles highlight why people have a hard time figuring out: “where do I go for [insert health concern here]?” How can I expect patients to get the answer right when the author of the article doesn’t? Consider:

“[Urgent Cares] often have X-ray equipment, CT scans, ability to do sutures, IV and so forth,” says Mehrotra. “In general most primary care practices cannot provide those kinds of services.”

I’ve worked in five different urgent cares and none had a CT scanner. If the doctor the WSJ interviewed thinks most urgent cares do, the average person isn’t going to know they don’t. The only thing worse than going to the wrong, expensive place, is having someone from that wrong, expensive place take your money and then send you to a second, more expensive place. Some urgent cares have relationships with nearby radiology centers, but if the urgent care staff think you’re having an emergency—most of the time, if you need a STAT CT, someone thinks you’re having an emergency—you’ll get sent to the ER. Many urgent cares also don’t provide IV fluids and instead send patients to the ER for them, although the spread of mobile IV centers that cater to drunk people may be helping expand access to IV fluids for minor dehydration and GI bugs.

As for sutures, whether your laceration is being repaired at an urgent care depends less on the physical resources at the urgent care, since they should all have basic suture materials, but on the human resource of “Who’s working?” An ER doctor working an Urgent Care shift won’t have any problem ruling out, say, a tendon injury or managing a multi-layer closure. A Family Practitioner, PA, or NP probably won’t have the same procedural training. A small bleeding vessel that might be easily tied off by an ER doc who has sutured thousands may be considered “too serious and requires an ER” by a new grad nurse practitioner (NP). The NP is doing the right thing by knowing what they can and can’t treat, but you won’t know who you’re going to see until you walk in the door. It’s expensive to staff urgent cares with physicians.

Urgent care is a great place to go to address immediate medical concerns when you can’t get an appointment with your doctor or it’s a weekend or evening and the office is closed. (If it’s potentially life-threatening, though, you should go to the ER.)

How many of us can get an appointment with our primary care provider (PCP) the same day, or by popping in? How many of us have a PCP? The National Association of Community Health Centers claims a third of Americans don’t have a PCP. My husband Jake and I are among them. I had a PCP who I’d known since I was 18: a wonderful man by the name of Dr. Walter Kmieciek. He died suddenly last year, leaving behind a grieving patient panel. He was wonderful and decidedly old-school, meaning he practiced like he wasn’t an employee of the private equity firms and hospital monopolies that’ve bought most private practices. He did this, however, at great detriment to his own time. He’d fit patients in, but he hated working for a medical practice that increasingly became about paperwork and insurance review, and that required so much unpaid overtime to do the right thing.

Kmieciek was ready to retire, as most docs who value the doctor patient relationship are. “Private equity” (PE) is a topic we can talk about another time (and we will!). PE has turned the physician into a “provider,” a replaceable cog expected to meet the demands and needs of the healthcare system instead of the patient. It’s bad for patients and it’s bad for the doctors who don’t want to, and shouldn’t have to, work that way. I’m on a waitlist to see a new PCP who works for my hospital system, but the waitlist for a “new patient appointment” is at least four months.

Care, even expensive, unnecessary care, can be better than no care. When there’s no PCP, however, care becomes fragmented, which means no preventative screening, no continuity of care, and no long-term monitoring. Which brings me to:

The number one challenge with urgent care centers is that they generally don’t have access to your electronic health record, which details your medical history and other important medical information, says Mehrotra.

This is not the urgent care’s number one challenge. Not even close. Urgent cares attempt to resolve the problem you came in with. You should be able to tell me if you have chronic medical problems, what meds you’re on, and the new acute complaint. Urgent cares aren’t setup for long-term care management. ERs and urgent cares fix immediate problems, not long-term progressive ones like chronic hypertension, diabetes, bad vibes, ennui, or “my wife doesn’t love me any more.” That last one is better addressed by a bar or a therapist. Kidding. Well, not about the therapist part.

The electronic health record is most helpful when monitoring a patient longitudinally and doesn’t yet replace a conversation. I can’t count the number of times I’ve tried talking to a patient in the ER who, instead of answering questions about their medical history, gets upset and asks me why I can’t just look in the chart. The chart may be, and frequently is, wrong or missing details.

In some communities, the vast majority of my ER patients could have been kept out of said Urgent Care or ER had their health been managed by a PCP who not only has the patient’s long-term records, but has been responsible for adjusting said patient’s care over time.  Although, as I said, my job is to make sure a patient isn’t immediately dying, I’ve started and adjusted diabetes, blood pressure, asthma, and epilepsy medications because I know, and the patient knows, they’re not going to follow-up with a PCP who doesn’t exist.

I think the actual number one challenge with urgent cares is heterogeneity. Like a box of chocolates, you don’t really know what you’re going to get. All urgent cares will, however, accept your co-pay and see you. They’re a bit like the Burger King of the healthcare world: have it your way. You go to the urgent care for antibiotics for your sore throat; they (frequently) give you antibiotics for your sore throat. Fantastic! But wait, did you actually need that antibiotic (your sore throat is likely caused by a virus) or did they give it to you because you expected something for your co-pay? There’s a saying in medicine: With antibiotics your cold will get better in seven days, otherwise it takes a week to recover. 

Before, or maybe after, you think I’m unfairly maligning urgent cares and letting PCPs and the ER off the hook, let me allow Pew Charitable Trust to back me up:

National treatment guidelines do not recommend antibiotic use for several acute respiratory conditions, including viral upper respiratory tract infections (common cold), bronchitis/bronchiolitis, asthma/allergy, influenza, nonsuppurative middle ear infections (characterized by non-infected fluid in the middle ear), and viral pneumonia.³ Because these conditions are either caused by viruses or are noninfectious, antibiotics are not effective.

Yet about 46 percent of all urgent care visits for non-antibiotic recommended diagnoses resulted in an antibiotic prescription. This is comparatively higher than other outpatient health care settings, such as retail clinics, emergency departments, and office-based clinics – where the same visits ended with a prescription some 14, 25, and 17 percent of the time, respectively.

I’m extremely tightfisted with antibiotics, because, while I love historical fiction, I don’t yearn to return to the days when people died from an infected splinter. The ER won’t shut its doors if my patient satisfaction scores are lower for not giving unnecessary antibiotics that breed resistance Some Augmentin recently resolved what could have become a life threatening infection in my husband, Jake, so I take the topic very personally. Will the memory of inappropriately prescribed Z-Packs make up for contracting a strain of super-resistant chlamydia?[3] No it will not. Plus, antibiotics can lead to weight gain and a nasty diarrheal colitis called C.Diff, which smells even worse than it sounds and can cause something called “toxic megacolon.”

The WSJ is right about one thing:

An urgent care doctor isn’t tracking your health over the long term or looking for patterns that may require new treatments. So especially if you have a complicated health history or chronic illnesses, relying too much on urgent care for treatment may mean you miss bigger problems. 

Many patients say the ER or urgent care is already doing preventative care, medication adjustments, and refills and referrals. But we’re not doing as good a job as a PCP. Tests, treatments, and screening, like referrals for colonoscopies and mammograms, won’t happen from the ER.

If I start you on a blood pressure medication but you never follow up with a PCP, I’ll never know that whether the blood pressure is being correctly treated. It’s like the difference between hooking up and getting married: a lot of important stuff isn’t going to happen in the hookup relationship, whatever its virtues. ER and Urgent Cares? Not the marrying kind.

“There are certain times where you should skip urgent care and head straight to the emergency department, says Friedman. This includes if you have any symptoms that might be a heart attack or stroke, such as chest pain or face numbness. If you’re struggling to breathe or have severe abdominal pain, it makes more sense to head to the ER rather than wasting time at an urgent care clinic that may end up sending you there.

…(If it’s potentially life-threatening, though, you should go to the ER.)”

True! But how do patients know if it’s potentially life threatening? I don’t always know, and I’m the ER doctor. Sometimes, it takes me multiple hours and a lot of fancy tests to figure it out. No one gets taught basic medical literacy in school. Not every serious medical problem starts with severe symptoms. Hopefully, you’ll keep joining me here for “Pulse Check” and we’ll try to find better ways to answer the question “what’s wrong and what do I do about it?” together.

If you’ve gotten this far, you’ve read through a lot of my opinions, but not necessarily clarifying and clear answers for whatever ails you. I’ve written a companion guide to each type of healthcare facility and what they offer, so the next time you have a medical problem, you can better decide where to go for the best quality care for the least hassle, money and time. The next post will be the guide. Stay tuned!

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[1] There are some efforts to create a vaccine against most rhinoviruses.

[2] Mostly.

[3] No chlamydia vaccine yet, either. When will OpenAI solve this problem?