A tale of two strep throats: Retail clinic vs. PCP

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Six years ago, just after arriving in Baltimore for a winter conference, I fell sick with fever and a bad sore throat.

After a night of feeling awful, I went looking for help. I found it at a Minute Clinic in a CVS near the hotel. I was seen right away by a friendly NP, who did a rapid strep test and prescribed me medication. I picked up my medication at the pharmacy there. The visit cost something like $85 and took maybe 30 minutes. They gave me forms to submit to my California insurance. And I was well enough to present my research as planned by day 3 of the conference.

Fast forward to this year. After feeling a bit blah on a Monday evening, I developed a sore throat, headache, and fever overnight.

I figured it was a winter viral pharyngitis, rearranged my schedule, and planned to make it an “easy day.” Usually a low-key day plus a good night’s sleep does the trick for me.

But not with this bug.

This one gave me chills, a splitting headache, body aches, a fever of 102, and a sense of serious misery. Plus that awful sore throat. A dose of ibuprofen 400 mg would beat back the symptoms a bit, and allow me to eat and sleep. But after about four hours, I’d find myself shivering and feeling horrible again.

And the following day, Wednesday, I felt even worse. I started wondering if maybe I had the flu, or could it be strep throat since I didn’t have a cough?

I thought about going to the doctor, but I felt so sick and I didn’t want to go through the hassle unless there was a decent chance of benefit.

Because, in truth, even though I get my care from a large well-regarded health system that offers online appointment scheduling, a portal to review my outpatient lab results, telephone advice nurses, and other conveniences, I still don’t like going in because it’s a big place and the experience never feels … delightful, shall we say.

I looked through UpToDate online and tried to figure out the likelihood that a doctor’s visit would change management (most adult pharyngitis is viral) but my mind was too fuzzy and so I stayed home in bed.

However, that night my husband said he was starting to get a sore throat. I also spoke to a doctor friend on the phone. She thought my symptoms sounded an awful lot like strep and urged me to go in and get a rapid strep test. I decided that if I didn’t feel a lot better by the next morning, I’d go in.

I was a little better the next morning (day 3 of my illness) but not a lot. The body aches were better, but I’d developed a killer earache, and it still hurt too much to eat unless I had recently taken ibuprofen. My temperature off ibuprofen remained 101 to 102 degrees.

So I called the phone appointment line, explained my symptoms, and was given an appointment to see my own assigned doctor. (No urgent care clinic available I was told; this health system encourages open access to your own doctors.)

As I had expected, it was a miserable hassle. The big facility’s big underground parking lot was full but they kept letting cars in, so I found myself along with twenty other cars on the bottom floor, with a staffer waving his arms and telling us to find a way to turn around.

My doctor’s waiting area was pleasantly uncrowded, and after I paid my $20 co-pay I was called by the medical assistant (MA) right away. This, I’ll admit, was nice. “How’re you doing?” she asked as we walked to the vitals station.

“Sick,” I replied. “That’s why I’m here. I haven’t felt this bad in years.”

The MA made a sympathetic noise, checked my vitals, and then put me in an exam room. She asked me to tell her about my symptoms, which I did.

And then she proceeded to quiz me about my lifestyle habits. Did I exercise regularly? Just what type of exercise do I do? How many times a week? And for how many minutes? What about drinking? How many times a week? How many drinks in an evening?

Now, I have always found it intrusive and annoying when clinic staff ask me these types of questions. I know why they do it and why it’s overall important, but as a patient I’ve always disliked it.

This time, having come for an acute care visit after feeling miserably sick for days, I was seriously annoyed. I have a low BMI, low blood pressure, and a beautiful lipid profile. (I credit genetics/epigenetics.) In other words, I am not in dire need of lifestyle interventions. But I gave the MA some brief answers and in truth I inflated my exercise levels a bit, because I didn’t want them to get on my case, or get distracted from my top priority, which was getting my illness evaluated.

A few minutes later, my doctor arrived. I had to repeat the story of my symptoms. She listened to my lungs and peered into my throat. And then she announced she would do a throat culture.

What? What about a rapid strep test, I wanted to know.

“This is a rapid test. It’s a rapid throat culture that gives us results in 6 to 8 hours. We don’t have any other strep tests.”

I looked at my watch. It was 11:40 a.m. “Let’s get your culture to the lab,” said my doctor. “If they start running it soon, we might have a result by evening. You can check online and if it comes back positive, call the advice nurse, and they’ll have a doctor order your prescription, which you could pick up tonight.”

I sat there, sick, spaced out, and very disappointed that there wasn’t a rapid strep test available.

My doctor handed me a paper bag. “Take this to the lab on your way out.”

It took me a little while to process this last bit. Not only did they not have a rapid strep test, but they were now telling me to go deliver my sample to the lab. Helpfully, the doctor gave me an “After Visit Instructions” handout, on which she had checked “Specimen drop off: Please take a number, and the next available receptionist will help you.”

I went to the lab. The waiting area was overflowing with people. I took a number (361) and then discovered they were now serving number 329; there were at least 30 people ahead of me. There was no bin or spot to drop off my specimen, so I sat huddled in a chair as my ibuprofen started wearing off, and my fever returned.

It took them twenty-five minutes to call my number. I had to tell them my name and address, and give them my ID again. “No co-pay required today!” the receptionist announced brightly. I told her I’d been waiting quite a while just to drop off a specimen and why didn’t they have a bin? She apologized and said they used to have something like that, but then the space was rearranged, and they took it away. I consoled myself thinking that since I’d dropped off my specimen at 12:25 p.m., hopefully I’d have a result by 8:30 p.m.

I went home to my bed and my ibuprofen. That evening I started checking the portal online. No result. No result. No result. I took more ibuprofen and spent another restless night with fever, sore throat, and earache.

The next morning, I checked again. Hallelujah! A positive strep culture! Which, I noticed, had been reported at 9:45 p.m. after the specimen was “collected” at 1:57 p.m.

I called the advice nurse, she arranged for the phone doc to call in my prescription, and then I had to schlep back to the health center to get my penicillin. And finally that afternoon, I started to really feel better.

Should I go to a retail clinic next time?

I don’t like being sick but it’s always instructive to be on the patient side of things.

Because my PCP didn’t offer a rapid strep test, my treatment was delayed by almost 24 hours. I lost an additional day of work and some income. My beleaguered spouse took care of our two little kids on his own for an extra day. Plus it’s not fun to have fever and a splitting earache.

All of these problems are a big deal to me. But they are an externality for the big organization that manages my health care. Rapid strep tests can be expensive for a provider; only 5 to 15 percent of adult pharyngitis is strep so unless you are selective about who gets tested, you end up with a lot of negative rapid tests that often get followed by a throat culture.

As for making your patients drop off their specimens at an over-crowded lab, well … it’s quite easy to see how that happens in a big organization. (Presumably it’s cheaper or easier than having staff do it.) I didn’t like it, but I’m not going to leave the provider over that.

I will, on the other hand, probably go look for a retail clinic next time I’m acutely ill and think I might have a treatable infection. I haven’t yet decided just how much a day of health is worth to me, but it’s surely more than the cost of a retail clinic visit minus my $20 copay.

Now, you may be scoffing and thinking that since I’m a doctor of course I can afford a retail visit. But if you have low socioeconomic status, a day not working can be an even bigger deal than it was for me. When I worked a salaried doctor job, I had paid sick days, but that’s not true for many workers.

However, I would be worried if many older adults with chronic health problems started going to retail clinics. That’s mainly because I’m skeptical that retail clinics can provide the right care — whether acute or chronic — to people who are medically complex and getting care from other providers.

I also worry that retail clinics will overprescribe antibiotics and other medications, in part because patients often want these things.

Of course, more conventional primary care urgent care clinics suffer from the same problems. Overprescribing of antibiotics is common in outpatient care, and medically complex people often get suboptimal care during acute and chronic visits. So perhaps it’s not fair to bash retail clinics excessively, until our primary care clinics get much better at what they do.

What constitutes good urgent care?

No matter what one’s age or medical history, one should be able to access a good urgent care experience when acutely ill. By good, I mean that:

  • The encounter involves a minimum amount of friction and burden. I put off my own doctor’s visit because I was reluctant to face the hassles while feeling sick. Imagine if I were employed and had canceled an additional day of clinic, in part because I was sick and avoiding the hassle of my doctor’s office. My employer and patients would’ve been upset, and rightly so.

  • Delays in diagnosis and treatment are minimized. Even when delays in treatment aren’t medically dangerous, they impose a serious burden on patients when the delays affect ability to work or care for others.

  • Diagnosis and treatment are in accordance with recommended practices. It can be hard to agree on the finer points of what is recommended practice, but, in general, care should be similar to what is recommended in UpToDate, for instance. Avoiding overprescribing of antibiotics is an issue in all urgent care settings. Should patients be quizzed about healthy lifestyle habits during an urgent care visit? This would be an interesting topic to debate, as it requires weighing population health benefits with patient satisfaction.

Will I go back to my PCP next time I need urgent care? Maybe, but if I think it’s strep again, I’ll probably look for a reliable urgent care provider who offers rapid strep tests. For working adults who aren’t medically complex, convenience and minimum delays in treatment are key.

Leslie Kernisan is an internal medicine physician and geriatrician who blogs at GeriTech.  She could be reached on Google+. This article originally appeared in the Health Care Blog.

Image credit: Shutterstock.com

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