urgent care medicine

Urgent Care Medicine vs Family Medicine

I’m biased towards urgent care medicine and this post will essentially be an advertisement for urgent care medicine because I find too much wrong with traditional family medicine.

I wrote a previous post on becoming an urgentologist.

 

Romanticism Of Family Medicine

I have often fantasized about moving to a small town and being the local town doctor. The go-to person for all health care issues. I’m sure it’s partly due to my narcissism but I hope there is some altruism there as well.

Family doctors in the past weren’t measured by the outcome of their patients’ lab values. They could see their church of patients and assure them or guide them on a healthier lifestyle choice. On occasion they might manage a few of their chronic diseases. But the family doctor’s main responsibility was to prevent disease.

Once antibiotics came on the scene in the 1920’s, pills became the magical cure. We can’t even stop ourselves from prescribing antibiotics for strep throat even though an incredibly small percentage of the strains cause complications. Even CAP’s are now considered to be mostly viral and rarely bacterial and thus not needing any intervention whatsoever.

 

Modern Family Medicine

The days are gone when I can walk in a patient’s room and address their lifestyle in place of prescribing a medication. For those of you not in family medicine, it’s not an exaggeration to say that I would be tarred and feathered if I were to recommend to someone to lose weight to address their acid reflux.

This isn’t a pity party for family doctors. Surgeons have their own battles with ever-busier surgical clinics and patients who insist on surgical interventions. Not to mention their patients having ever-increasing health issues complicating the outcomes of the surgeries.

 

Urgent Care Medicine

Yes, urgent care medicine is as heavenly as I’m painting it. Think about it, you get to address often one single issue. Even better, it’s often an acute issue that the patient hasn’t had enough time to build an identity around. It’s an ache, a rash, a sensation, a worry, a bump, or a simple request.

As clinicians we tend to recall all the difficult cases of the day because that’s where the majority of our ATP’s are spent. In fact, 80% of our patients are ridiculously simple to manage and 10% might require a bit of workup and the other 10% are outpatient disasters.

I’ve only been burned by complicated cases which should have been in the ER for the necessary shotgun approach.

 

Schedule of Urgent Care Medicine

The schedule in urgent care medicine is often ideal in all aspects except the social one. If you are the kind of person that wants to socialize with friends and family in the evenings and weekends then the urgent care medicine schedule will often interfere with that.

If instead you like to have your mornings free and avoid busy commute times then UC is absolutely ideal. You also get to work on weekends which is the time when everything you want to do is packed with others who had the same idea.

Most urgent cares don’t have patients scheduled in specific time slots. It’s often a walk-in system. This puts a little less pressure on the clinician. It’s inevitable in family medicine to fall behind when your patient’s agenda isn’t clocked to a watch.

Finally, your patients will be incredibly grateful that you are available to them after they get off work or when they have some free time on the weekend.

 

Family Medicine Schedule

The way family medicine currently works is absolutely idiotic. Patients are seen during times when they are working. And few doctors have evening or weekend clinics which guarantees that such patients will end up in the UC or the ED for their more acute needs.

The schedule is also build around productivity and not patient needs. There is no intelligent algorithm to identify higher-need patients and plug them into larger slots.

Any disaster in the schedule falls on the shoulder of the family medicine clinician who has to take on more stress to make up for the time. That can’t be healthy.

 

The Family Medicine Mentality

In FM we chastise patients for their lifestyles and diets and we admonish them for not taking their medications the way they should be. It can easily become a patronizing interaction.

There is absolutely no time to investigate what side effects the medications are causing which could be contributing to their lack of compliance. And we certainly don’t have time to address the fears and worries regarding the medications.

We are told by management, legal, and attending to discuss the side effects of the medications with the patients in the exam room when prescribing. Are you kidding me? Which family medicine clinician has time to discuss the side effects of coumadin? How about SSRI’s?

You just spent 25 minutes during a 15 minutes appointment convincing the patient that they need antidepressants. Are you now going to discuss all the interactions and side effects and risks of stopping it abruptly? Or the countless interactions with OTC medications, not to mention supplements?

We are taught in family medicine to make decisions with the patients and not for them. What we’re really taught is to make patients dependent on us. We put our own agendas of BP and DM control of theirs when the office visit starts. There is minima patient empowerment in family medicine.

The Urgent Care Medicine Mentality

I’m not saying urgent care medicine is perfect but at least it’s legit. Patient comes in for abdominal complaints and I suspect it’s diverticulitis. History confirms this and a CBC shows slight elevated WBC’s though that’s not even needed due to the location and characteristics of the exam. I prescribe a couple of antibiotics and send the patient on their way.

As an urgent care medicine provider I don’t have to spend time with the patient discussing their high animal protein diet which is likely leading to their diverticula. Not discuss the lack of fiber. I won’t have to bother telling them that the data regarding seeds is bullshit.

The patient came to the urgent care for the pain and the fevers. Diagnosis made. Medications prescribed. And I have plenty of time to discuss (briefly) the side effects of the medications.

In an urgent care medicine visit I’m there to discuss whatever they are there to discuss.

Want to talk about chronic parasitic infections?
Want to discuss your chronic EBV infection?
What about your symptoms which are likely sequelae of undiagnosed Lyme Disease?
Worried that the 12 home pregnancy tests you did are false-negatives and you want a serum test?
Absolutely! I’m here to hear all the online theories.

The point is that I’m following the patient’s agenda and not my own. If there is time, if the opportunity arises to offer some education then I will do so.

Primary Care Is Customer Service, It’s Retail Medicine

The chronically ill don’t get better. In order to get better there has to be a significant effort on the patient’s part. And in their defense our society has become one of disempowered citizens.

Owning your health means having to point the finger at yourself. It requires using a healthcare professional as a consultant and not a pharmacist, in order to figure out the best direction to take.

Many doctors deny that medicine has become a retail and customer service field. Perhaps they have the strength and conviction to stand up to the institution of medicine and do what’s right for the patient. The doctors who have been most loved by their patients are, in my blighted opinion, the ones who are willing to acquiesce to the patients the most.

I used to say that practicing evidence-based medicine was the way to go. Now, with the evidence coming from the pharmaceutical and device manufacturing industries, it’s probably the wrong thing to do.

Vacations

I think it’s really tough to get vacation time in family medicine. Naturally, patients are scheduled far in advance and taking time off means having to cancel appointments.

In contrast, a well-run urgent care medicine department will have a solid backup and per diem pool which allows for the urgent care providers to have more vacation flexibility.

The “Losing my skills” Argument

You come out of residency and you’ve done ICU, inpatient medicine, OB, psychiatry, and a ton of peds. You get into family medicine and you see old, fat, depressed people. (I’m sure there was a nicer way for me to express this).

When you work in the urgent care you get to take care of post-op patients, you get to do a ton of procedures, and you still have to do a lot of family medicine work.

Trust me, you won’t forget how to titrate up lisinopril by doing urgent care medicine instead of family medicine. But you might forget to recognize angioedema from a swollen eyelid, dismissing it as “allergies”.

The “High Acuity” Myth of Urgent Care medicine

Listen, maybe the urgent care providers are telling you that they deal with high acuity because they want to make their job sound more exciting than it really is. 80% of what we see is absolutely not acute. Just like ED docs, we rarely see true emergencies or urgencies.

During the cold and flu season it’s common to see 95% cold and flu stuff for several months straight. During the summer months you’ll barely see any patients and during the holidays you’ll see lonely people who crave attention.

The chest pain and shortness of breath patients are almost always transferred out of the urgent care as soon as some basic testing is done on them. My colleagues would relate to me how “scary” their shift was because they had to call 911 on a chest pain patient. That’s what nurses and bystanders do … what’s so hard about that? Anxiety-producing, yes. Difficult, no.

What about procedures? Most abscesses don’t need I&D. Most lacerations don’t need suturing. Most peritonsillar abscesses don’t need draining. Most fractures don’t need to be set. Most foreign bodies don’t need to be removed.

Being able to triage a patient effectively is the most valuable skill you can possess as an urgent care provider. You can’t depend on a union nurse to do it unless you are with a stellar staff member. You need to hone your differential diagnosis to include giant cell arteritis for a headache or a metastatic disease from a breast CA that went into remission 25 years ago.

Job Opportunities

Currently there is a higher need for family medicine providers than urgent care providers. The caveat to that is that most of the family medicine positions are for full-time providers.

The positions available for urgent care providers can often be negotiated to be part-time or per diem. And that’s a huge bonus in my option.

Making The Job Switch

It’s far easier to switch from urgent care to family medicine than vice versa. This should be an important consideration when coming out of residency or taking on a new job at a medical group.

As a family doctor you’ll have developed a panel of patients. They will have assigned you a 1:1 staff member. There will be case managers and diabetic nurses who have learned your idiosyncrasies. Leaving abruptly as a family medicine clinician is really tough on the medical group.

However, in urgent care medicine you can give your notice and bounce. You’ll be replaced fairly easily. There will barely be any disruption. This also happens to be great if you enjoy job mobility.

Job Mobility

Most larger medical groups allow you to move laterally or vertically within the organization. This might be in the form of taking on admin role or performing other clinical roles.

As a family medicine provider with a panel of patients it will be less likely for your supervisor to want to let you go. This would create a lot of work for them in having to replace you which might impede your ability to move within the company.

As an urgent care provider you can move much easier. You can even take on clinical roles in pediatrics, in the ED, in occupational medicine and other departments because of your knowledge managing a much larger breadth of complaints.

Few Regret the switch

I know of only 1 provider in my 10 years who switched from family medicine to urgent care medicine and regretted it.

The 1 clinician I recall who didn’t do well in the urgent care environment originally came from family medicine because he was burnt out there. His performance was so bad that they wanted to let him go. Instead, they agreed to let him try out urgent care medicine as a last resort. He ended up trying to switch back to family medicine but they wouldn’t take him.

When I look at my colleagues and friends who made the switch I only hear positive remarks. These providers did the whole family medicine thing with a massive panel. Brutal. That’s hard work.

Once they switched to urgent care medicine they realized how much less work it is. How much less drama there is in the urgent care setting and how much faster they can get out of the room, onto the next patient.

The Future of Medicine

When I look at the direction medicine is going in, I don’t see family medicine being a sustainable career. I believe there will be more and more jobs in family medicine because of the aging population.

With the massive intelligent data collection coming on the scene, family medicine providers will be scrutinized like never before. They will be tasked with more and more babysitting of data.

Urgent care medicine will continue to be the stopgap between the ED and FM. The patient isn’t sick enough or doesn’t have the money to go to the ED but they can’t or aren’t willing to wait for a primary care appointment.

Medicine will need to provide more and more access to patients and with the ridiculous panel sizes these days, urgent care providers will be the only ones with enough free time to address the needs of these patients.

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