What Do Free-Standing ERs Say About Us and Our Patients? by Stella Fitzgibbons MD

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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!

Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  4 comments for “What Do Free-Standing ERs Say About Us and Our Patients? by Stella Fitzgibbons MD

  1. Seneca
    March 9, 2015 at 3:49 pm

    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.

  2. Pat
    March 9, 2015 at 12:29 pm

    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.

    • David Ferrand
      March 9, 2015 at 5:07 pm

      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…

  3. JRDO
    March 9, 2015 at 10:38 am

    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.

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