[This post was first published on The Health Care Blog on 1/28/15, and was re-posted to KevinMD on 2/21/15. The comments are worth reading at both sites.]
Six
years ago, just after arriving in Baltimore for a winter conference, I fell
sick with fever and a bad sore throat.
years ago, just after arriving in Baltimore for a winter conference, I fell
sick with fever and a bad sore throat.
After
a night of feeling awful, I went looking for help. I found it at a Minute
Clinic in a CVS near the hotel. I was seen right away by a friendly NP who did
a rapid strep test, and prescribed me medication. I picked up my medication at
the pharmacy there. The visit cost something like $85, and took maybe 30
minutes. They gave me forms to submit to my California insurance. And I was
well enough to present my research as planned by day 3 of the conference.
a night of feeling awful, I went looking for help. I found it at a Minute
Clinic in a CVS near the hotel. I was seen right away by a friendly NP who did
a rapid strep test, and prescribed me medication. I picked up my medication at
the pharmacy there. The visit cost something like $85, and took maybe 30
minutes. They gave me forms to submit to my California insurance. And I was
well enough to present my research as planned by day 3 of the conference.
Fast
forward to this year. After feeling a bit blah on a Monday evening, I developed
a sore throat, headache, and fever overnight.
forward to this year. After feeling a bit blah on a Monday evening, I developed
a sore throat, headache, and fever overnight.
I
figured it was a winter viral pharyngitis, rearranged my schedule, and planned
to make it an “easy day.” Usually a low-key day plus a good night’s sleep does
the trick for me.
figured it was a winter viral pharyngitis, rearranged my schedule, and planned
to make it an “easy day.” Usually a low-key day plus a good night’s sleep does
the trick for me.
But
not with this bug. This one gave me chills, a splitting headache, body aches, a
fever of 102, and a sense of serious misery. Plus that awful sore throat. A
dose of ibuprofen 400mg would beat back the symptoms a bit, and allow me to eat
and sleep. But after about four hours, I’d find myself shivering and feeling
horrible again.
not with this bug. This one gave me chills, a splitting headache, body aches, a
fever of 102, and a sense of serious misery. Plus that awful sore throat. A
dose of ibuprofen 400mg would beat back the symptoms a bit, and allow me to eat
and sleep. But after about four hours, I’d find myself shivering and feeling
horrible again.
And
the following day, Wednesday, I felt even worse. I started wondering if maybe I
had the flu, or could it be strep throat, since I didn’t have a cough?
the following day, Wednesday, I felt even worse. I started wondering if maybe I
had the flu, or could it be strep throat, since I didn’t have a cough?
I
thought about going to the doctor, but I felt so sick and I didn’t want to go
through the hassle unless there was a decent chance of benefit.
thought about going to the doctor, but I felt so sick and I didn’t want to go
through the hassle unless there was a decent chance of benefit.
Because
in truth, even though I get my care from a large well-regarded health system
that offers online appointment scheduling, a portal to review my outpatient lab
results, telephone advice nurses, and other conveniences, I still don’t like
going in because it’s a big place and the experience never feels…delightful,
shall we say.
in truth, even though I get my care from a large well-regarded health system
that offers online appointment scheduling, a portal to review my outpatient lab
results, telephone advice nurses, and other conveniences, I still don’t like
going in because it’s a big place and the experience never feels…delightful,
shall we say.
I
looked through UpToDate online and tried to figure out the likelihood that a
doctor’s visit would change management (most adult pharyngitis is viral) but my
mind was too fuzzy and so I stayed home in bed.
looked through UpToDate online and tried to figure out the likelihood that a
doctor’s visit would change management (most adult pharyngitis is viral) but my
mind was too fuzzy and so I stayed home in bed.
However,
that night my husband said he was starting to get a sore throat. I also spoke
to a doctor friend on the phone. She thought my symptoms sounded an awful lot like
strep, and urged me to go in and get a rapid strep test. I decided that if I
didn’t feel a lot better by the next morning, I’d go in.
that night my husband said he was starting to get a sore throat. I also spoke
to a doctor friend on the phone. She thought my symptoms sounded an awful lot like
strep, and urged me to go in and get a rapid strep test. I decided that if I
didn’t feel a lot better by the next morning, I’d go in.
I
was a little better the next morning (day #3 of my illness) but not a lot. The
body aches were better, but I’d developed a killer earache, and it still hurt
too much to eat unless I had recently taken ibuprofen. My temperature off
ibuprofen remained 101-102.
was a little better the next morning (day #3 of my illness) but not a lot. The
body aches were better, but I’d developed a killer earache, and it still hurt
too much to eat unless I had recently taken ibuprofen. My temperature off
ibuprofen remained 101-102.
So
I called the phone appointment line, explained my symptoms, and was given an
appointment to see my own assigned doctor. (No urgent care clinic available I
was told; this health system encourages open access to your own doctors.)
I called the phone appointment line, explained my symptoms, and was given an
appointment to see my own assigned doctor. (No urgent care clinic available I
was told; this health system encourages open access to your own doctors.)
As
I had expected, it was a miserable hassle.
I had expected, it was a miserable hassle.
The big facility’s big underground
parking lot was full but they kept letting cars in, so I found myself along
with twenty other cars on the bottom floor, with a staffer waving his arms and
telling us to find a way to turn around.
My
doctor’s waiting area was pleasantly uncrowded, and after I’d paid my $20
co-pay I was called by the medical assistant (MA) right away. This, I’ll admit,
was nice. “How’re you doing?” she asked as we walked to the vitals station.
doctor’s waiting area was pleasantly uncrowded, and after I’d paid my $20
co-pay I was called by the medical assistant (MA) right away. This, I’ll admit,
was nice. “How’re you doing?” she asked as we walked to the vitals station.
“Sick,”
I replied. “That’s why I’m here. I haven’t felt this bad in years.”
I replied. “That’s why I’m here. I haven’t felt this bad in years.”
The
MA made a sympathetic noise, checked my vitals, and then put me in an exam
room. She asked me to tell her about my symptoms, which I did.
MA made a sympathetic noise, checked my vitals, and then put me in an exam
room. She asked me to tell her about my symptoms, which I did.
And
then she proceeded to quiz me about my lifestyle habits. Did I exercise
regularly? Just what type of exercise do I do? How many times a week? And for
how many minutes? What about drinking? How many times a week? How many drinks
in an evening?
then she proceeded to quiz me about my lifestyle habits. Did I exercise
regularly? Just what type of exercise do I do? How many times a week? And for
how many minutes? What about drinking? How many times a week? How many drinks
in an evening?
Now,
I have always found it intrusive and annoying when clinic staff ask me these
types of questions. I know why they do it and why it’s overall important, but
as a patient I’ve always disliked it.
I have always found it intrusive and annoying when clinic staff ask me these
types of questions. I know why they do it and why it’s overall important, but
as a patient I’ve always disliked it.
This
time, having come for an acute care visit after feeling miserably sick for
days, I was seriously annoyed. I have a low BMI, low blood pressure, and a
beautiful lipid profile. (I credit genetics/epigenetics.) In other words, I am
not in dire need of lifestyle interventions. But I gave the MA some brief
answers and in truth I inflated my exercise levels a bit, because I didn’t want
them to get on my case, or get distracted from my top priority, which was
getting my illness evaluated.
time, having come for an acute care visit after feeling miserably sick for
days, I was seriously annoyed. I have a low BMI, low blood pressure, and a
beautiful lipid profile. (I credit genetics/epigenetics.) In other words, I am
not in dire need of lifestyle interventions. But I gave the MA some brief
answers and in truth I inflated my exercise levels a bit, because I didn’t want
them to get on my case, or get distracted from my top priority, which was
getting my illness evaluated.
A
few minutes later, my doctor arrived. I had to repeat the story of my symptoms.
She listened to my lungs and peered in my throat. And then she announced she
would do a throat culture.
few minutes later, my doctor arrived. I had to repeat the story of my symptoms.
She listened to my lungs and peered in my throat. And then she announced she
would do a throat culture.
What?
What about a rapid strep test, I wanted to know.
What about a rapid strep test, I wanted to know.
“This
is a rapid test. It’s a rapid throat culture which gives us results in 6-8
hours. We don’t have any other strep tests.”
is a rapid test. It’s a rapid throat culture which gives us results in 6-8
hours. We don’t have any other strep tests.”
I
looked at my watch. It was 11:40am. “Let’s get your culture in to the lab,”
said my doctor. “If they start running it soon, we might have a result by
evening. You can check online and if it comes back positive, call the advice
nurse and they’ll have a doctor order your prescription, which you could pick
up tonight.”
looked at my watch. It was 11:40am. “Let’s get your culture in to the lab,”
said my doctor. “If they start running it soon, we might have a result by
evening. You can check online and if it comes back positive, call the advice
nurse and they’ll have a doctor order your prescription, which you could pick
up tonight.”
I
sat there, sick, spaced out, and very disappointed that there wasn’t a rapid
strep test available.
sat there, sick, spaced out, and very disappointed that there wasn’t a rapid
strep test available.
My
doctor handed me a paper bag. “Take this to the lab on your way out.”
doctor handed me a paper bag. “Take this to the lab on your way out.”
It
took me a little while to process this last bit. Not only did they not have a
rapid strep test, but they were now telling me to go deliver my sample to the
lab. Helpfully, the doctor gave me a “After Visit Instructions” handout, on
which she had checked “Specimen drop off: Please take a number and the next
available receptionist will help you.”
took me a little while to process this last bit. Not only did they not have a
rapid strep test, but they were now telling me to go deliver my sample to the
lab. Helpfully, the doctor gave me a “After Visit Instructions” handout, on
which she had checked “Specimen drop off: Please take a number and the next
available receptionist will help you.”
I
went to the lab. The waiting area was overflowing with people. I took a number
(361) and then discovered they were now serving number 329; there were at least
30 people ahead of me. There was no bin or spot to drop off my specimen, so I
sat huddled in a chair as my ibuprofen started wearing off and my fever
returned.
went to the lab. The waiting area was overflowing with people. I took a number
(361) and then discovered they were now serving number 329; there were at least
30 people ahead of me. There was no bin or spot to drop off my specimen, so I
sat huddled in a chair as my ibuprofen started wearing off and my fever
returned.
It
took them twenty-five minutes to call my number. I had to tell them my name and
address, and give them my ID again. “No co-pay required today!” the
receptionist announced brightly. I told her I’d been waiting quite a while just
to drop off a specimen and why didn’t they have a bin? She apologized and said
they used to have something like that, but then the space was rearranged and
they took it away. I consoled myself thinking that since I’d dropped off my
specimen at 12:25pm, hopefully I’d have a result by 8:30pm.
took them twenty-five minutes to call my number. I had to tell them my name and
address, and give them my ID again. “No co-pay required today!” the
receptionist announced brightly. I told her I’d been waiting quite a while just
to drop off a specimen and why didn’t they have a bin? She apologized and said
they used to have something like that, but then the space was rearranged and
they took it away. I consoled myself thinking that since I’d dropped off my
specimen at 12:25pm, hopefully I’d have a result by 8:30pm.
I
went home to my bed and my ibuprofen. That evening I started checking the
portal online. No result. No result. No result. I took more ibuprofen and spent
another restless night with fever, sore throat, and earache.
went home to my bed and my ibuprofen. That evening I started checking the
portal online. No result. No result. No result. I took more ibuprofen and spent
another restless night with fever, sore throat, and earache.
The
next morning, I checked again. Hallelujah! A positive strep culture! Which, I
noticed, had been reported at 9:45pm after the specimen was “collected” at
1:57pm.
next morning, I checked again. Hallelujah! A positive strep culture! Which, I
noticed, had been reported at 9:45pm after the specimen was “collected” at
1:57pm.
I called the advice
nurse, she arranged for the phone doc to call in my prescription, and then I
had to schlep back to the health center to get my penicillin. And finally that
afternoon, I started to really feel better.
Should I go to a retail clinic next time?
I
don’t like being sick but it’s always instructive to be on the patient side of
things.
don’t like being sick but it’s always instructive to be on the patient side of
things.
Because
my PCP didn’t offer a rapid strep test, my treatment was delayed by almost 24
hours. I lost an additional day of work and some income. My beleaguered spouse
took care of our two little kids on his own for an extra day. Plus it’s not fun
to have fever and a splitting earache.
my PCP didn’t offer a rapid strep test, my treatment was delayed by almost 24
hours. I lost an additional day of work and some income. My beleaguered spouse
took care of our two little kids on his own for an extra day. Plus it’s not fun
to have fever and a splitting earache.
All
of these problems are a big deal to me. But they are an externality for the big
organization that manages my healthcare. Rapid-strep tests can be expensive for
a provider; only 5-15% of adult pharyngitis is strep so unless you are
selective about who gets tested, you end up with a lot of negative rapid tests
that often get followed by a throat culture.
of these problems are a big deal to me. But they are an externality for the big
organization that manages my healthcare. Rapid-strep tests can be expensive for
a provider; only 5-15% of adult pharyngitis is strep so unless you are
selective about who gets tested, you end up with a lot of negative rapid tests
that often get followed by a throat culture.
As
for making your patients drop off their specimens at an over-crowded lab,
well…it’s quite easy to see how that happens in a big organization. (Presumably
it’s cheaper or easier than having staff do it.) I didn’t like it but I’m not
going to leave the provider over that.
for making your patients drop off their specimens at an over-crowded lab,
well…it’s quite easy to see how that happens in a big organization. (Presumably
it’s cheaper or easier than having staff do it.) I didn’t like it but I’m not
going to leave the provider over that.
I
will, on the other hand, probably go look for a retail clinic next time I’m
acutely ill and think I might have a treatable infection. I haven’t yet decided
just how much a day of health is worth to me, but it’s surely more than the
cost of a retail clinic visit minus my $20 copay.
will, on the other hand, probably go look for a retail clinic next time I’m
acutely ill and think I might have a treatable infection. I haven’t yet decided
just how much a day of health is worth to me, but it’s surely more than the
cost of a retail clinic visit minus my $20 copay.
Now,
you may be scoffing and thinking that since I’m a doctor of course I can afford
a retail visit. But if you have low socio-economic status, a day not working
can be an even bigger deal than it was for me. When I worked a salaried doctor
job I had paid sick days, but that’s not true for
many workers.
you may be scoffing and thinking that since I’m a doctor of course I can afford
a retail visit. But if you have low socio-economic status, a day not working
can be an even bigger deal than it was for me. When I worked a salaried doctor
job I had paid sick days, but that’s not true for
many workers.
However,
I would be worried if many older adults with chronic health problems started
going to retail clinics. That’s mainly because I’m skeptical that retail
clinics can provide the right care – whether acute or chronic – to people who
are medically complex and getting care from other providers.
I would be worried if many older adults with chronic health problems started
going to retail clinics. That’s mainly because I’m skeptical that retail
clinics can provide the right care – whether acute or chronic – to people who
are medically complex and getting care from other providers.
I
also worry that retail clinics will over-prescribe antibiotics and other
medications, in part because patients often want these things.
also worry that retail clinics will over-prescribe antibiotics and other
medications, in part because patients often want these things.
Of
course, more conventional primary care urgent care clinics suffer from the same
problems. Over-prescribing
of antibiotics
is common in outpatient care, and medically complex people often get
sub-optimal care during acute and chronic visits. So perhaps it’s not fair to
bash retail clinics excessively, until our primary care clinics get much better
at what they do.
course, more conventional primary care urgent care clinics suffer from the same
problems. Over-prescribing
of antibiotics
is common in outpatient care, and medically complex people often get
sub-optimal care during acute and chronic visits. So perhaps it’s not fair to
bash retail clinics excessively, until our primary care clinics get much better
at what they do.
What constitutes good urgent care?
No
matter what one’s age or medical history, one should be able to access a good
urgent care experience when acutely ill. By good, I mean that:
matter what one’s age or medical history, one should be able to access a good
urgent care experience when acutely ill. By good, I mean that:
·
The encounter
involves a minimum amount of friction and burden. I put off my
own doctor’s visit because I was reluctant to face the hassles while feeling
sick. Imagine if I were employed and had cancelled an additional day of clinic,
in part because I was sick and avoiding the hassle of my doctor’s office. My
employer and patients would’ve been upset, and rightly so.
The encounter
involves a minimum amount of friction and burden. I put off my
own doctor’s visit because I was reluctant to face the hassles while feeling
sick. Imagine if I were employed and had cancelled an additional day of clinic,
in part because I was sick and avoiding the hassle of my doctor’s office. My
employer and patients would’ve been upset, and rightly so.
·
Delays in
diagnosis and treatment are minimized. Even when delays in treatment aren’t
medically dangerous, they impose a serious burden on patients when the delays
affect ability to work or care for others.
Delays in
diagnosis and treatment are minimized. Even when delays in treatment aren’t
medically dangerous, they impose a serious burden on patients when the delays
affect ability to work or care for others.
·
Diagnosis and
treatment are in accordance with recommended practices. It can be hard to agree on the finer
points of what is recommended practice, but in general, care should be similar
to what is recommended in UpToDate, for instance. Avoiding over-prescribing of
antibiotics is an issue in all urgent care settings.
Diagnosis and
treatment are in accordance with recommended practices. It can be hard to agree on the finer
points of what is recommended practice, but in general, care should be similar
to what is recommended in UpToDate, for instance. Avoiding over-prescribing of
antibiotics is an issue in all urgent care settings.
Should
patients be quizzed about healthy lifestyle habits during an urgent care visit?
This would be an interesting topic to debate, as it requires weighing
population health benefits with patient satisfaction.
patients be quizzed about healthy lifestyle habits during an urgent care visit?
This would be an interesting topic to debate, as it requires weighing
population health benefits with patient satisfaction.
Will
I go back to my PCP next time I need urgent care? Maybe, but if I think it’s
strep again, I’ll probably look for a reliable urgent care provider who offers
rapid strep tests. For working adults who aren’t medically complex, convenience
and minimum delays in treatment are key.
I go back to my PCP next time I need urgent care? Maybe, but if I think it’s
strep again, I’ll probably look for a reliable urgent care provider who offers
rapid strep tests. For working adults who aren’t medically complex, convenience
and minimum delays in treatment are key.
Ok, so here is my equation: ((Scripted medical questioning) + (Lack of true reasoning)) / insurance interference and rejection = Chaos. Sorry, I'm too far too cynical these days to accept this paradigm. Hope you feel better! this was a GREAT article. Remember folks, when you hear hoofs, don't think Zebras.
I really liked this article and will recommend it. I recently had an experience which left me very frustrated with primary care as well although I don't believe an Urgent Care clinic would have been of help here. I am a retired Pain Management, Oncology, and Palliative Care nurse who has persistent pain (persistent post craniotomy pain). In September I woke up with excruciating pain in my left leg. .I take scheduled pain medicine for my PPC pain so I hated to think how bad it would be. I didn't take breakthrough medication because of the agreement you sign with pain medications (except when It caused my PPC pain to flare). At 10 days I couldn't take this anymore so I tried to get in to see my PCP-got sent to a PA instead. She couldn't give me a diagnosis (with my Hx as an Oncology nurse, I was worrying about a pathological fracture) and she didn't do tests until someone had been in pain at least 2 weeks. See was unhappy I couldn't take NSAIDs, told me the opioids just masked the pain (which as some one who has presented nationally and been published in different aspects of pain and pain management-I had to disabuse her of), and wanted me to start PT right away (which I declined to do without a Dx). At two weeks still terrible pain, couldn't get in to see anyone and then developed pain and symptoms indicative of a possible DVT. Now they told me to go to an ED where I had a hip x-ray done and an ultrasound. No fracture and instead of a DVT I ended up with superficial clots along the medial aspect of upper and lower leg-now I had pain on the other side of the leg which didn't respond to opioids well (one of my colleagues suggested Lidoderm patches and they did work well). It took me a month to make it to an Orthopedic surgeon. I have bursitis and tendonitis. After a cortisone shot and 2 days a week of PT I still have some pain and the physician thinks I may have scar tissue under one of the tendons which may need to be addressed. My link to this story is why would they make anyone "wait" in pain and why wasn't there an immediate referral to the Orthopedic surgeon. If I would have had an obvious injury it would have occurred immediately. Fortunately I am retired now which mean work was not affected however I have the care much of the time of three grandchildren-one who is 3 who really didn't get why Grandma was hurting so much.
The questions with the med tech or nurse are annoying especially in acute situations especially if you have one who doesn't know you. Having to answer questions which have nothing to do with your reason for being there is stressful as well.
Thank you both for these comments. Yes, it's definitely hard to get the right care at the right time. My own problem was minor (miserable, but not long-lasting). I cringe thinking what things must be like for those with more serious needs, like Janice with chronic pain.
I had a similar thing happen to me with strep throat. Except my two experiences with step weren't quite a year apart. It came back a few months after having it the first time, and they just gave me some different medication. My doctor didn't even test me for strep. He just assumed it was the problem, since it was the same symptoms as before. The different medication worked pretty well, as I haven't gotten strep since.