After a 30-year career in the ED, I decided to pack it in at the dawn of my next 10-year certification for reasons I noted in June 2009 issue of EMN. (http://emn.online/2956K8D.) I have worked part-time in urgent care since then.
Urgent care is a medical care paradigm of the past five years. It suffers the problems associated with the new. In particular, some of the worst substandard care I've seen in my career is a product of urgent care centers in which I've worked treating returning patients with avoidable complications and treatment failures for one reason or another.
The worst have been in hospital-run urgent care centers. The reason is they are by and large managed by the family practice department and specifically FP managers who fail to understand the FP paradigm is far different from the urgent care paradigm. Some of the best urgent care centers have been the chains and franchises with the mom-and-pop operations some place in-between.
The family practice paradigm manages conditions and diseases to prevent exacerbations and related untoward consequences. Hypertension and hyperlipidemia treatment, for instance, forestalls or prevents TIA, stroke, heart attack, peripheral vascular disease, claudication, and amputations. The same holds true for diabetes, arthritis, thyroid disease, migraine, COPD, asthma, and gout. The primary care mission is, to a great degree, enhanced quality of life.
The urgent care paradigm deals primarily with exacerbations of the diseases and maladies managed by family practice, which ordinarily does not deal with exacerbations. Urgent care also deals with lacerations, contusions, sprains, fractures (ability to interpret x-rays with some reasonable expertise), epistaxis, pneumonia, acute bronchitis, exacerbation COPD, etc. To accomplish this mission, urgent care needs to be staffed, equipped, and supplied very differently from the FP office.
Some of the worst suturing I've seen in my career on a consistent basis is from an urgent care center. Failed treatment for a variety of reasons are too frequent in urgent care. An example: A patient suffers a through-and-through hand puncture wound from a contaminated nail. The puncture wounds are sutured closed! A staff person diplomatically inquires why she didn't see the web prescription for antibiotics come through, to which the response is, “We don't use prophylactic antibiotics.” Of course, antibiotics are not prophylactic but the treatment. The patient returns few days later with massively swollen, red, hot hand, and an I&D yields a large amount of pus. He is sent to the ED, and spends five days in hospital on IV antibiotics.
Another case: A woman exquisitely sensitive to poison ivy returns three days after treatment feeling a little better. Her face is red and she has adnexa of her eyes, with edematous lids swollen half shut. I ask what medicine she is on. She doesn't know, but recognizes word prednisone. I think that's strange so I retrieve chart and find she was placed on 30 mg prednisone for three days.
And take this case: A triangular flap laceration over an Achilles tendon apex cephalad amounts to a full-thickness skin graft, an almost perfect triangle three inches on a side. This flap had to be badly retracted with significant distractive force. It really required some vertical mattress sutures, but had tiny 5-0 nylon sutures placed so close to the skin edge that half had pulled out, the flap retracted, and a cellulitis extended up the calf.
One last case: A woman arrives in acute respiratory distress. Fortunately, the physician on duty is current in endotracheal intubation. The blades do not fit the laryngoscope handle, and no meds are available for intubation. An urgent care crash cart should be no different from that found in a freestanding surgery center or the med/surg hospital floor, and should be inspected daily.
I get several calls a day and many emails to work in urgent care. There is an enormous shortage of qualified doctors to work there. Most freshly minted doctors out of FP residency are not qualified to staff urgent care.
Urgent care is a new paradigm that requires a new breed of physician. The emergency physician is overqualified and the FP distinctly underqualified in most instances. This is not a belittlement of FPs any more than it would be belittling to criticize me for not being able to fly a Boeing 777 after 40 years of flying single-engine planes.
The American Medical Association and the American Osteopathic Association should approve two-year fellowships in urgent care medicine for physicians board certified in a primary care specialty. The fellows would train in EDs alongside emergency medicine residents but concentrate on the urgent care paradigm leading to board certification in urgent care medicine.
Carl J. VanderPutten, DO