— Can’t we improve primary care and emergency department visits so more patients go there instead?
by Fred Pelzman, MD, Contributing Writer, MedPage Today November 20, 2023
Fred Pelzman is an associate professor of medicine at Weill Cornell, and has been a practicing internist for nearly 30 years. He is medical director of Weill Cornell Internal Medicine Associates.
Wouldn’t it be better if we just fix what was broken, since we know how to do this?
In this Sunday’s New York Times there was a full double-spread in the Sunday Business section about the importance and growth of urgent care centers and the role they play in healthcare. These facilities have blossomed over the past few years, and growth was only fueled and accelerated by the pandemic. Clearly, they provide an incredible service to patients, fitting a specific niche between primary care and the care needed in an emergency department.
But is this really something we need to have growing? Wouldn’t it be better if we just made the other ends of the spectrum, both the primary care and the emergency department experiences, much better for all of those involved?
We’ve all seen examples of patients who have gone into urgent care centers with a cough, congestion, and sore throat, who get sent home with a cough suppressant, an antibiotic, a course of oral steroids, and one or two inhalers. These days, they also often get a full respiratory pathogen panel, including influenza, respiratory syncytial virus (RSV), and COVID-19, and a whole host of other viruses, which may, at times, be clinically relevant.
We’ve all heard stories of patients who’ve been seen at these centers, got some treatments, and amazingly felt better the next day. But sometimes we’re left to clean up the mess. (Interestingly, on page 7 of the front section of the same day’s New York Times was a full-page ad brought to us by the makers of Mucinex decrying antibiotic overuse and suggesting use of over-the-counter treatments for viral upper respiratory infections.)
Many of the complaints voiced by patients in the urgent care center article were about the inability to reach their primary care doctor, the inability to get a same-day appointment there, and the incredible waste, inefficiencies, and overcrowding in our emergency departments. Those of us who work in these sites, the primary care doctors and the emergency room doctors, all wish that our patients had exactly the experience they needed in getting timely care at each of these locations.
Wouldn’t it be in the interest of our patients, our providers, our healthcare system, the economy, and our society as a whole if, instead of growing this in-between section, we fixed things around the edges?
There are so many things that need to be addressed: the inequities in healthcare access for our patients; the geographic maldistribution of care from generations of institutional racism and bias; and the inability of patients to get virtual visits and telehealth even though leaving their job or families for several hours to get care creates an additional burden.
Other issues include no one answering the phones; scheduling inefficiencies; high no-show rates that prevent others from being seen; and the wrong care provided at the wrong time. All of this is burdening an already overwhelmed primary care system that is laboring under intense pressures to produce volume, all while managing thousands of in-basket messages, forms, and click-boxes in the electronic medical record.
Then there are the countless hours we spend each day dealing with insurance companies, pointless regulatory requirements, and frustrating hurdles and barriers put up by the healthcare system — not to mention our lack of someplace to send our patients, with specialist and subspecialist schedules booking out 6 months, often because they are filled up with “routine” visits, patients returning to them with chronic problems that could certainly be handed back to their primary care doctors.
If we create a better primary care system, an incredibly strong base of fully reimbursed and rewarded providers who are not burned out and who practice in a fully supported environment, we’d be better able to handle the patients that present to our emergency rooms and even these urgent care centers with “primary care-responsive” symptoms and diseases, like upper respiratory tract infections, chronic low back pain, and urinary tract infections.
We all have parts to play, but sometimes these challenges seem insurmountable. No matter how much we talk about this, no matter how many arguments we make for building up primary care, and how much advice is offered from those of us working on the front lines, it feels like it keeps falling on ears that are unwilling to listen. For now, these urgent care centers will continue to thrive (and grow), because they are taking overflow from a broken system that can’t handle what it should be designed to manage with ease.
I love that our patients have a place to go on weekends when we’re not in practice (read “home with our families”), or for a minor laceration or sprain that doesn’t require the full attention of the emergency department physicians and their skill sets. But as these centers slide down the slippery slope toward managing chronic problems like hypertension and diabetes, we should recognize this as a symptom of all that is broken in healthcare.
And turn our attention to fixing it, once and for all.