Working in an urgent care center: An assault on the soul

I recently received this email message from one of my residents who has moonlighted in a local commercial urgent care center. This message is reprinted with his permission just as I received it, except I removed the brand name.

Hey Dr. Young, I’m looking for some basic mentoring advice.  I’ve been moonlighting at ZZZ Urgent Care for about a year.  Not my favorite work, but oh well.  I don’t routinely prescribe antibiotics for URI, but I have gotten a little heat for “underprescribing” as well as not ordering enough additional tests.  Apparently, some patients have complained when I did not give an antibiotic.  I always anticipate that people expect antibiotics and go into this long drawn out explanation why they don’t need them.  I hope information will help them understand (and many really do get it, I think) that they can just treat their URI symptomatically.  Recently there was a newsletter basically encouraging antibiotics for any URI.  I find this unethical.  Someone got fired for not prescribing enough antibiotics.  I’m ok with getting fired, because I feel strongly that we should do what’s right.  I just wanted to see if there is another side to the story that I’m overlooking.  I have at times given pushy patients antibiotics and told them to hold them for several days before taking them. Any thoughts?  Am I overly concerned about proper medical practices?  Should I just go along with their recommendations recognizing that I’m working for an organization that calls the shots?

I have had this discussion with many of my residents. I talk to them about having to sell their soul to the devil of non-evidence-based medical practice just to make it through a shift at one of these places without having a crisis of conscience.

This is a difficult position for residents, or any other doctors with ethics, to be in. I remember what it was like, approaching age 30 after accumulating medical school debt (average of about $160,000 these days) while making about $47,000 a year as an intern and resident in training. Many of my residents have families and children to support. Working at one of these places on a weekend or evening (“moonlighting”) provides much needed financial resources at a crucial time in their lives.

I don’t condemn my residents from working in these places, but I help them develop some psychological armor to withstand the assault on their souls. But I also exhort them to not practice in this style when they have their own practices after graduation.

I’m quite sure my resident is not alone, nor that my region is particularly full of unethical urgent care facilities. They’ve sprouted up like mushrooms all over the country in high income zip codes.

From a policy perspective, here are a few thoughts for non-healthcare industry benefits managers, CFOs, CEOs, and others worried about appropriate utilization and the high cost of healthcare.

1. Urgent care centers often provide horrible care.

  • They skim the easy work – they sew up the laceration in an inebriated person, but take no responsibility for the alcoholism, depression, and high blood pressure – and overcharge for the easy work to boot.
  • They medicalize normal life. They make people with colds feel like they should come running back to the urgent care center every time they have a sniffle. This creates excessive utilization for that person and her family for years afterwards. As a corollary, they over-prescribe antibiotics and give way too many steroid shots. This contributes to antibiotic resistance across the country.
  • Their business managers pressure the doctors to order more X-rays than is necessary. This resident’s report is not the first time I’ve heard of this attitude.

2. Urgent care centers have thrived because the insurance companies, Medicare, and Medicaid will pay $150 to one of these facilities, but only $70 to a family medicine center for the same work (plus the urgent care centers don’t take responsibility for the more difficult issues). If you were an entrepreneur, would you build more urgent care facilities or family medicine centers?  Exactly.

3. Urgent care centers are the cautionary tale for the policy wonks who want doctors to provide more patient-centered care. These places functionally operate as McClinics: “Which antibiotic would you like?  The pink one?  Excellent choice Madame!”

The corollary to this last point, is that policy makers and payers should not seek patient-centered doctors; they should seek system-centered doctors. Not just at urgent care centers, but all over the healthcare system, physicians should be supported when they do the right thing, even if it means they won’t get a “5” on their patient satisfaction scorecard. Denying requests for antibiotics for colds, MRIs for acute low back pain, and hydrocodone for minor injuries are some of the difficult conversations that ethical physicians should have with their patients. A dissatisfied patient who had demanded antibiotics for a cold is the best outcome.

I am so gratified that this resident and many other physicians have chosen not to sell their medical ethical souls. You are unlikely to find a high-quality physician such as this at a commercial urgent care center.

Richard Young is a physician who blogs at American Health Scare.

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  • betsynicoletti

    I once begged my PA for antibiotics for sinusitis. He took the time to explain why not. But, I’m a coding educator and I said, “Tony, if you give me antibiotics it can move the visit from a 99213 to a 99214. It’s a win/win!” He laughed, but still didn’t provide antibiotics. All of you clinicians out there won’t be surprised to know I got better a few days later anyway.

    • Terry Evans

      The best explanation I have ever seen to explain to patients why they don’t really want antibiotics for that cough, cold or flu came from the WhiteCoat blog:

      “Using antibiotics on virus infections is like using Raid on
      dandelion infestations. Both chemicals kill things, but neither one is
      able to kill the things we’re trying to get rid of. Your body is going to have to fight this one out on it’s own, but I’ll help you control the symptoms while it does.”

      I work in the clinic on a large university campus and if we’d paid Mr Whtecoat royalties every time we used that line and had it work, he could probably retire tomorrow.

      • betsynicoletti

        Great — and fun–explanation.

      • http://www.facebook.com/people/Tom-Fitzsimmons/1405121136 Tom Fitzsimmons

        No. People with asthma soon learn that any prolonged congestion will lead to infection. This is not from ‘some bug’ we have acquired but is from the bacteria that are already happily living in our lungs. When I show up with my $150 one shot attempt at medical care it is out of desperation and I better walk out with the prescriptions I came for. I pay you to write prescriptions. What I don’t want is the latest medical trend espoused by some person I don’t know from Adam and who does not know me.

        • http://www.facebook.com/people/Jason-Simpson/100001631757606 Jason Simpson

          Ummm you can buy any medicine you want from an online pharmacy in Mexico with no prescription! Why are you giving doctors a hard time? Go do it yourself and good luck! LMAO

        • http://www.facebook.com/marilyn.shively.5 Marilyn Shively

          you can’t be serious

  • Zachary Leonard, MPAS, PA-C

    I can’t speak for commercial Urgent Cares, but as a small-community Urgent Care PA, I feel I practice incredibly ethical medicine. I’ll absolutely take the time to explain why patients don’t need an antibiotic, and not feel pressured when they demand it. I do believe that medicare reimburses more for urgent cares because sometimes the problems are urgent, but not emergent. Patients will see me when their PCP can’t squeeze them in for an appointment. Furthermore, I often do have to deal with the “difficult problems” because of the primary care shortage in the community. I regularly have to manage substance abuse/withdraw, hypertension, diabetes, and depression because patients have nowhere else to go. I wouldn’t say working in an Urgent Care is easy at all!

    • Richard_Young_MD

      Zachary,
      It sounds like you provide an important service with integrity. I’m just not sure you’re in the majority, especially when decisions come down to doing the right thing from a societal point of view vs. pleasing a demanding patient.

  • http://www.facebook.com/profile.php?id=100002542862252 Gaylen Marie

    i worked in an urgent care that was in the same space as md offices. the fee was the same $69 for an office visit as for an urgent care visit. if the pcp could not fit the pt. into the schedule we were to put the pt into urgent care. many pts. did this if their pcp was also going to be the urgent care m.d. from 5-7pm on certain days. i would have rather died than gone to that urgent care. most ended up needing care from an e.r. so now they have 2 fees to pay. the urgent care most often did not suture, or do any dirty work. many, many pts came out very disgusted with the care they were given and having wasted their money. last week my husband was directed to go there because he could not get in to see anyone in his regular m.d. office. he said he would rather die. he ended up going to a hand surgeon who did an i & d to the finger. our pcp would have never done that and that urgent care – oh – laugh way way out loud – would not have touched it. they are a waste of insurance money and pts. money. also – if you do not have insurance – they can turn you away unlike an emergency room. this urgent care required you to pay $100.00 before you could be seen. then imagine how happy a patient would be to then be told – oh – we cannot help you, go to e.r. or – wait it out for another 7-10 days. they should all be closed.

    • Trisha

      “they should all be closed”

      Then what would people do if they need out of hours care, or to see a doctor before their own doctor could squeeze them in (ie several days to a week), but it was not an ER type emergency? Like, with uncontrolled vomiting after hours that just needs some Zofran, or a bad cut while surfing that just needs a couple of stitches?

      Also, I don’t have insurance so would much prefer to pay $100 to get some Zofran at the care clinic than be up for hundreds if not thousands by going to the ER.

      • Richard_Young_MD

        Trisha,
        If family physicians were actually paid for the work we do, there would be enough of them in the workforce to provide more timely services. I would love to be part of a large clinic that provides the services you list, but the government and insurance companies have to change their payment policies for this to happen.

    • Richard_Young_MD

      Gaylen Marie,
      And the family medicine centers should be incentivized to provide a full complement of cognitive and procedural services so that this run around and resulting delayed and expensive care is much less likely to happen.

  • Homeless

    RE: I talk to them about having to sell their soul to the devil of non-evidence-based medical practice …

    Like the evidence on the value of annual physicals…or for mammograms for women under 40?

    • Richard_Young_MD

      I agree annual physicals are a waste. I’m not aware that a lot of primary care physicians order mammograms for women under 40.

      • DebMatthewsresign

        Puzzled by waste of time of annual physicals

      • DebMatthewsresign

        incidence of undiagnosed diabetes and HBP is increasing How will these conditions be diagnosed if folks don’t go for an annual physical?

        • Richard_Young_MD

          The U.S. Preventive Services Task Force concluded there is insufficient evidence to support screening for diabetes in any patients except those with high blood pressure. I’m pretty sure the similar agency in Britain concluded that there is no good evidence for any patient population.

          Therefore, diabetes will be discovered the way most other diseases are: when there are symptoms raising the possibility the disease is present. On the other hand, so many Americans have their blood drawn at the drop of a hat, diabetes will certainly be detected occasionally through this mechanism.

  • http://www.facebook.com/vikas.desai.92560 Vikas Desai

    There is no reason why a busy primary care office can’t double as an urgent care if we had the appropriate staff and facility plus we actually care about the people we see. Unfortunately we neither can afford the staff and thus we cannot stay open as long because we don’t get paid anywhere close to what these guys do. They cherry pick all the easy cases(much like the minute clinic) and leave the real work to the PMD’s and ER docs, while making more than either combined.

    • Richard_Young_MD

      And we must actually be paid for the complex work we do.

  • buzzkillerjsmith

    Whoa Nelly! You say that UC medicine is an assault on the soul. Absolutely right. But then you go way too far, stating that “this resident and many other physicians have chosen not to sell their medical ethical souls.” I would submit that if they wind up working for Corpmed, and many of them will, their souls will be bought and paid for. Maybe not on the first shift they work, as in the case of UC, but give it time. A couple months maybe.

    • Richard_Young_MD

      Buzz Killer,
      Actually most of my residents grit their teeth and put up with it for a while. They can’t wait to exit the environment. Of course, a few get comfortable in that setting and stay.

  • Markus Unread

    Again we have another overreaching, super judgmental piece on KevMD (I’m referring back to the assisted suicide article). The treatment at an UC facility may not be up to the standards professed by this particular PCP, but it is often the only choice available outside of the ER. “they should seek system-centered doctors” – This has to be coming from someone who has never practiced in under-served, rural or poor areas. There are more and more areas in the United States fitting this description every day. In those areas, finding healthcare of any kind is “an assault on the soul” – and the wallet.

    • Suzi Q 38

      I think that there should be a few more of them in certain busy cities.
      The government should figure out how to treat all the illegals and indigent patients with these UC offices. It would save a lot of money.
      First line for coughs and colds would be the UC.
      This would make the hospital ER’s free to see the real emergencies.

      • Richard_Young_MD

        Suzi Q,
        Don’t go to the doctor for a cold. Prescribe yourself a big dose of patience instead.

        • Suzi Q 38

          No, I don’t go to the doctor for colds. As far as a dose of patience, I wholeheartedly agree.

    • Richard_Young_MD

      Markus,
      This is an interesting comment. I work at a county hospital safety net environment where 58 languages are spoken and every one of my patients is poor. The reasons that urgent care centers are often the only option in many communities have been described above.

  • http://www.facebook.com/dave.james.90410 Dave James

    Agree that urgent cares are often “money mills” especially the ones with CT scanners, MRI and the like. But emergency rooms of most hospitals grossly over utilize labs and imaging. Just last week (yet again) a patient was referred after 4 visits to the ER for the same ureteral stone. Of course after 4 CT scans for a stone obvious on KUB. Lack of history taking or brain use??

    • Richard_Young_MD

      Dave,
      In a conversation with a highly-published ER physician, I asked him about this issue of ER docs ordering so many CT scans. I was actually giving them just a smidge of sympathy because of lawsuit pressures. He waived that statement off and retorted that they’re just too lazy to take a history.

  • Sudeep

    This is a rather lofty position to take on urgent care! I suppose the rest of medicine is completely ethical? As a primary care physician who has also worked in urgent care for many years, I can tell you that both arenas have the pressure to try and maximize revenue from our fee-for-service system. I hope you advised your resident that life will be full of decisions involving ethics, and that money will never be an excuse for making the wrong decision. This is a rather prejudiced and misinformed article…what’s next? All international medical graduates are idiots?

    • Richard_Young_MD

      Sudeep,

      This resident’s email to me has been circulated among all of our residents (with his permission). It has actually been a great catalyst for meaningful discussions of the pressures physicians face to provide inappropriate care from several directions, which absolutely includes patients. I refer you to the asthma/bacteria comment above.

      One of the most broadly-skilled and honorable physicians I’ve had the privilege to work with in my department is from Chennai.

  • http://twitter.com/cleduke Catherine LeDuke

    I also take issue with the judgmental tone of this piece. There are all kinds of people out there with all kinds of wants and needs when it comes to healthcare. As always, the onus should fall to the consumer and their choices and preferences should run the show. But that’s not the way it works, ha! (Who has that last laugh?) Perhaps if traditional doc offices could find it in their business model to fill out their hours (just think about the ramifications of staying open through the lunch hours, in some capacity) and make it easier for people to get healthcare via the doc office pathway, urgent care centers and retail clinics would not seem so onerous and soul-sucking.

    • Richard_Young_MD

      Catherine,

      I agree that family physicians should step up to the plate and provide more hours of coverage to their patients. The reasons they don’t very often provide this service now are really quite simple: they’re not paid to do so. The payers pay an ER $900 to care for a patient with a bad cough, and the family physician at most about $100. This is why urgent care centers and free-standing ERs have sprouted up like mushrooms across America.

  • Varun Kejriwal

    There are so many factors involved in the efficacy of an urgent care center, many of which have been brought up in the comments.

    As @zrleonard:disqus brought up, the perspective of the provider matters. Dr. Young, your resident was also an example of someone working in an urgent care clinic who could influence the environment/patients positively. I’m not saying he created direct change, but the more providers like him who are willing to spend their time in an urgent care clinic could lead to some influential pull. It is unfortunate that providers are laid off and chastised in these settings for not providing the give-and-go style of care that pulls in the case. But that can be changed.

    As @facebook-100004016337423:disqus and @twitter-197279796:disqus brought up, the nature of the clinic’s operations make a difference. Although many UCs are disconnected from a proper system-style of care (which I support in the fight against bad health), a clinic that personalizes its care in a “normal clinic” setting doesn’t have to sacrifice care when it flips to “urgent-care mode.” Even if the clinic is urgent-care only, why can’t it have an infrastructure that keeps it in close communication with an incoming patient’s primary providers? Sure they might not be available to communicate right then and there, but there could be a streamlined system that allows for cross-talk between providers in order to bolster organic accountability.

    Finally, as @suzi_q_38:disqus mentions, there could be a system that facilitates a step-by-step process in choosing when and where to receive care. We have a lot of intelligent risk analysis tools and healthcare professionals who can triage certain conditions quickly. For example, how about UTIs? Can urinary tract infections not be screened over the phone? If there was a standardized way of caring for after-hours conditions, we would be able to influence UCs in a way that would integrate them more effectively into the larger healthcare system.

    Looking forward to hearing more thoughts,
    Varun
    Moxe Health

    • Richard_Young_MD

      Varun,
      Great thoughts. I would love to handle simple UTIs in low-risk women over the phone. I just need to be paid for the work. It doesn’t have to be much, but I must be paid for my expertise, patient communication, documentation time, and medico-legal risk.

  • dom

    just one comment…doing the right thing gets you “5″s and that has absolutely noting to do with writing unnecessary prescriptions or doing unnecessary tests. its about connecting with the patients and improving their outcome.

    • Richard_Young_MD

      Dom,
      Yes but our patients live in a culture that assumes more is always better. They underestimate the harms of over-testing and over-treatment. There are studies showing that more satisfied patients have higher mortality rates. Our entire country needs to develop a new sense of what excellent medical care looks like.

      • Bubbles99

        As a patient, I can tell you that is absolutely not true. You’re over-emotionalizing the irrational “princess” patients, and ignoring the majority of quiet patients who understand that “more is never more” — that treatments carry costs as well as side effects.

        • Richard_Young_MD

          Bubbles,
          Both from my personal experience working in many different facilities and recent discussions with some benefits managers at large companies, I’m afraid the more-is-better patient population is larger than the quiet patients. I hope I’m wrong. Perhaps both the HR people and I are just used to seeing the more demanding employee/patients.

          Also, perhaps the literature on how most Americans over-estimate the benefits of chemotherapy speaks to this issue.

  • Bubbles99

    Versus my own doctors’ office, who insisted that I drive across town and sit in their waiting room for two hours to maybe eventually see a doctor, when I had a fever of 104 with recurrent pneumonia (self-diagnosed by the rice krispie sounds emanating from my chest).

    I finally cursed and brow-beat an ER doctor into calling in a prescription for an antibiotic I’d had for my LAST pneumonia, and presto, three days later, fever gone and symptoms subsiding (and yes, I finished the full course of antibiotics.

    If I had a dime for every time I heard patients blamed for the state of America’s health care, I’d be richer than an orthopedic surgeon with artificial hip “research” grants.

  • Suzi Q 38

    Patients will always ask.
    I wish doctors will just get used to it.
    If you have to say “no,” just say it and tell the patient why.
    If you explain it well, most will comply.
    For that small percentage that will not take “no” for an answer,
    Ask them why they think they need it so bad.
    Tell them that you will write the script for the antibiotic, but they are to visit the website on the internet that explains why it is not a good idea. Have a photocopied piece of paper that has the pertinent website listed.
    If they agree with the article, do not fill the prescription. Wait until the symptoms get worse.
    Maybe for these individuals, they need the “control.”

  • Antonio

    I appreciate the issue of prescribing Antibiotics for the wrong reason. Its been an issue for years for all medical personell. However to paint Urgent Cares as unethical or unable to find a high quality physician in one of them is just crossing the line. Yes, there are commercial venture capitalist owned Urgent Cares who I have seen push the extra costs for profit margin sake, but its not typical of most Urgent Cares. I challenge you to find one urgent care physician at my facility that is not more qualified than you. We employ only residency trained board certified Emergency medicine physicians. No PA or NP. We offer high quality care at a low cost. I am not sure about your prices in Urgent Cares, but they are not close to what you are stating here. I wish Medicare paid that much. Average charges for our patients and most reputable Urgent Care centers is around $100. Medicare pays much less, and Medicaid pays essentially nothing. We do take all cases, and many are refered by Primary Care physician’s offices and “high quality” physicians when they can’t handle the case in their office like hypertensive emergency, abcesses, complex lacerations, dehydration, etc. We also see many patients because “high quality” physicians are not convinient due to not able to get them in on the patient time, lunch time, evenings and weekends. They find that a visit at our Urgent Care Center takes usually under 30 min total time, better then spending a few hours in their PCP office. I would love to show you my Urgent Care system, and get you information on it.

  • http://www.facebook.com/expressfamilycare John Smith

    I apologize for being late in this conversation but, since I’m a primary care physician, I am never off. Being a primary care physician is the “assault on the soul.” Not just working in an urgent care. I’ve done both and the only difference in one vs. the other is the service that is provided in the urgent care. I still got slammed by demanding patients for antibiotics, tests, etc. in the “traditional” PCP office. You are who you are no matter where you work. You CHOOSE to practice good medicine vs. bad medicine according to the person you are. The problem is the system. I think the only way that remains to practice academic medicine is to practice in an academic setting. Even that may be in question now. And, heaven forbid you go to an underserved area where there is no cross-coverage. There is no solution in sight and the problem will only get worse with the flooding of the system when Obamacare takes place. If you believe anything different, you are only kidding yourself. I love being a physician. I hate practicing in this system.

  • http://www.facebook.com/coleen.g.wheeler Coleen Gosnell Wheeler

    I take particular offense to this article. I was in Family Practice for 20 years, but the current atmosphere drove me away. I was an excellent FP and I carry the same excellence into my work in an Urgent Care Clinic. The statement that you will not find quality physicians working in Urgent Care is offensive and FALSE!