What Do Free-Standing ERs Say About Us and Our Patients? by Stella Fitzgibbons MD
Thanks to laws that make it easy for them to operate, Texas has a burgeoning number of 24-hour clinics and free-standing ERs, two of which employ me (oh, fine, they contract with the doctor group that pays me, but the outcome is the same). Patients come in with minor injuries and with illnesses that got worse outside of office hours…but also with minor acute problems that could have been handled in their primary care doctor’s office.
My ERs are pretty low-volume (4-12 patients a shift), so I have the time to call the primary care doc and relate what happened if it’s important (I had to stop an ACE inhibitor due to the cough, that walking pneumonia in a 70-year-old needs to be seen again soon, etc.). Most patients seem to appreciate this, even if a few are a little miffed at being ratted out.
Having done primary care of outpatients for 15 years I understand what a pain in the schedule those walk-ins can be. And many primary care docs don’t realize that the receptionist has heard them complain about double booking enough that she just tells the patient to come in 24 hours from now–long enough to let a pyelonephritis worsen or gastroenteritis cause significant dehydration.
Larger doctor groups have a number of options: let one doc a day be the walk-in guy, set up a “service on demand” area in the same building, etc. etc. But is there any way for hard-working generalists to deal with the public’s increasing demand for no-waiting medical care? Comments, please!
I do not any incentive for a physician to provide longitudinal care any longer. In fact, all the hoops we jump through to keep social justice warriors happy does nothing to improve quality; rather, it accelerates the race to retirement by the older cadre of physicians who are still providing this service. As a 56 year old FP, I saw myself practicing well into my 70’s if my health will allow–now I think I can comfortably get out in my early 60’s and am looking forward to it. It is not too improbable that in the next 10 years most outpatient primary care will be through ER’s, urgent care practices, and PA/NP practices. Physician work is rarely scalable or adapted to automation–it remains an interaction between one doctor and one patient. Such thinking is anathema to any B-school graduate trying to siphon money off productive physicians. Unfortunately, all too many of us have given up and signed up with Corp Med. I guess we get what we deserve.
With respect to ER’s, the confluence of EMTALA and the threat of malpractice guarantee 24/7 access. Add to this the growing number of government dependent patients – Medicaid and Medicare – who have no negative financial consequence for coming to the ER for anything no matter how minor. Any primary care doc will have to compete with a large population that is demanding and entitled to go to the ER; which is staffed by docs who have no power to curb their unreasonable behavior, are scared of being sued if they did, and who are increasingly happy to just give them the damn Z-pack in order to get them out.
No one will hold these patients accountable so, sorry, there is no fix for this.
The door swings both ways here… I’ve had hundreds of patients who only come to me in the ED because they couldn’t get an appointment for days or weeks with their PCP, for an obvious acute illness. While I agree that many urgent cares should be shut down as antibiotic pill mills, and that I’ve seen some serious dereliction of standard of care from some free-standing ED’s, I can also tell you that I seem to observe that many PCP’s are just as likely to “give the damn Z-pack” as the LELT in the urgent care or Minute Clinic.
There are indeed a lot of patients who abuse the privilege of having EMTALA mandated care, and have no financial disincentive for doing so, but they also many times don’t have any other outlet. I understand there are often logistic reasons why a small office can’t handle a walk in acute care patient at 16:47 in the afternoon on Friday, but I’ve seen some pretty clear cases of laziness in telling the patient to go to the ED (or perhaps they just couldn’t stand to see that same fibromyalgia ridden patient again…)
You want a good core measure? How about the percentage of abx scripts given per patient encounter? Even as a dumb ED doc, I’m confident that I could pass on the lowest percentile on that one…
I have a love-hate relationship with the urgent cares/free-standing ERs in my area. I like the fact that my patients can get seen during my off hours, but the care given can be inappropriate at times (e.g. Levaquin for a 2 day history of clear watery nasal discharge). It seems to me that urgent cares are the places where some patients go to get what they want (antibiotics, pain rx) when they have a sense that their PCP won’t acquiesce to their demands. That’s not really a comment about …”the public’s increasing demand for no-waiting medical care?”, but it is a part of a trend of patients demanding to be get whatever they want- whether it is good for them or not. I worry that many urgent cares in my area are more business oriented with a “the customer is always right” mentality rather than focusing on what is best for the patient. BTW, I recently had a patients tell me that they have got a Z-packs from an area urgent cares with the physician being in the room with them for less than 1 minute with no physical exam having been done at all.