I recently received this email message from one of my residents who has moonlighted in a local commercial urgent care center. This message is reprinted with his permission just as I received it, except I removed the brand name.

“Hey Dr. Young, I’m looking for some basic mentoring advice.  I’ve been moonlighting at ZZZ Urgent Care for about a year.  Not my favorite work, but oh well.  I don’t routinely prescribe antibiotics for URI, but I have gotten a little heat for “underprescribing” as well as not ordering enough additional tests (cbc, cxr, etc.).  Apparently, some patients have complained when I did not give an antibiotic.  I always anticipate that people expect antibiotics and go into this long drawn out explanation why they don’t need them.  I hope information will help them understand (and many really do get it, I think) that they can just treat their URI symptomatically.  Recently there was a newsletter basically encouraging abx for any URI.  I find this unethical.  Someone got fired for not prescribing enough abx.  I’m ok with getting fired, because I feel strongly that we should do what’s right.  I just wanted to see if there is another side to the story that I’m overlooking.  I have at times given pushy patients antibiotics and told them to hold them for several days before taking them…….Any thoughts?  Am I overly concerned about proper medical practices?  Should I just go along with their recommendations recognizing that I’m working for an organization that calls the shots?”

I have had this discussion with many of my residents. I talk to them about having to sell their soul to the devil of non-evidence-based medical practice just to make it through a shift at one of these places without having a crisis of conscience.

This is a difficult position for residents, or any other doctors with ethics, to be in. I remember what it was like, approaching age 30 after accumulating medical school debt (average of about $160,000 these days) while making about $47,000 a year as an intern and resident in training. Many of my residents have families and children to support. Working at one of these places on a weekend or evening (“moonlighting”) provides much needed financial resources at a crucial time in their lives.

I don’t condemn my residents from working in these places, but I help them develop some psychological armor to withstand the assault on their souls. But I also exhort them to not practice in this style when they have their own practices after graduation.

I’m quite sure my resident is not alone, nor that my region is particularly full of unethical urgent care facilities. They’ve sprouted up like mushrooms all over the country in high income zip codes.

From a policy perspective, here are a few thoughts for non-healthcare industry benefits managers, CFOs, CEOs, and others worried about appropriate utilization and the high cost of healthcare.

1) Urgent care centers often provide horrible care.

1. They skim the easy work – they sew up the laceration in an inebriated person, but take no responsibility for the alcoholism, depression, and high blood pressure – and overcharge for the easy work to boot.
2. They medicalize normal life. They make people with colds feel like they should come running back to the urgent care center every time they have a sniffle. This creates excessive utilization for that person and her family for years afterwards. As a corollary, they over-prescribe antibiotics and give way too many steroid shots. This contributes to antibiotic resistance across the country.
3. Their business managers pressure the doctors to order more X-rays than is necessary. This resident’s report is not the first time I’ve heard of this attitude.

2) Urgent care centers have thrived because the insurance companies, Medicare, and Medicaid will pay $150 to one of these facilities, but only $70 to a family medicine center for the same work (plus the urgent care centers don’t take responsibility for the more difficult issues). If you were an entrepreneur, would you build more urgent care facilities or family medicine centers?  Exactly.

3) Urgent care centers are the cautionary tale for the policy wonks who want doctors to provide more patient-centered care. These places functionally operate as McClinics: “Which antibiotic would you like?  The pink one?  Excellent choice Madame!”

The corollary to this last point 3), is that policy makers and payers should not seek patient-centered doctors; they should seek system-centered doctors. Not just at urgent care centers, but all over the healthcare system, physicians should be supported when they do the right thing, even if it means they won’t get a “5” on their patient satisfaction scorecard. Denying requests for antibiotics for colds, MRIs for acute low back pain, and hydrocodone for minor injuries are some of the difficult conversations that ethical physicians should have with their patients. A dissatisfied patient who had demanded antibiotics for a cold is the best outcome.

I am so gratified that this resident and many other physicians have chosen not to sell their medical ethical souls. You are unlikely to find a high-quality physician such as this at a commercial urgent care center.

Tags: ethics, healthcare quality, over-utilization, patient-centered, urgent care

This entry was posted on February 17, 2013 at 2:02 pm and is filed under Blog. You can follow any responses to this entry through the RSS 2.0 feed.