“So long as I know it not, it hurteth me not.”
—George Pettie, 1576
George Pettie, an English writer, had it wrong. What you don’t know can hurt you. I remember when I saw my first urgent care center, shortly after I went into practice in 1989. My first thought was, “Well, that is a good idea.” It seemed a logical bridge between going to the emergency room, with the expense and long waits, and trying to get into a doctor’s office, which can be next to impossible on an urgent basis. I could imagine many medical conditions that were not true emergencies but could not wait for a routine office appointment, either. For years, I assumed that patients going to such centers saw a physician, or at least had their care supervised by a physician. Like Pettie, I was wrong.
I recently learned some very disturbing things about how urgent care is being provided in many centers. One local urgent care center has six locations. It is owned by a physician assistant (PA). Physician assistants have a very limited medical education. To become a PA, you must have a bachelor’s degree and complete the two-year curriculum to be certified as a PA. Some, but not all, PA programs require that the applicant have some “experience.” This can be as a medical assistant, nursing assistant, laboratory technician, phlebotomist (blood draw technician), or even as a Peace Corps volunteer!
Now, back to our urgent care center. Each center has shifts staffed by a nurse practitioner (NP) and a couple of medical assistants (MAs). Pathways vary to becoming a NP, but for most, you have to have a bachelor’s degree and be a registered nurse. Then, you typically do a two-year master’s program, including classroom and clinical work, to become a NP. Some NP programs require or request that applicants have worked as a nurse for a couple of years or more before applying. You can become an MA with as little as a high school diploma or GED and some on-the-job training under a physician. Some formal programs offer a certificate in as few as nine months.
So, now you have the urgent care center owned by a PA and staffed by NPs and MAs. Where’s the physician? You know, the person who has undergone at least four years of medical school education after college, and a minimum of three years of hands-on clinical patient management in an accredited residency to become board-certified in a specialty, such as family or emergency medicine.
Well, that center employs two physicians to cover the six locations. Why? Because, hard to believe as it may be, there are still some things physicians are legally allowed to do that PAs, NPs, and MAs cannot, although those are becoming fewer and fewer. This particular urgent care center employs a couple of physicians who are basically retired but still keeping themselves in the game, so to speak, by covering the six centers and signing charts, orders, and so on as necessary. One is in his 80s and, reportedly, spends most of his time asleep in a back room. Sadly, some physicians practice beyond any reasonable age because their financial planning for retirement was insufficient or because they can’t seem to quit practicing, even in such a desultory manner.
OK, so we have NPs and MAs serving as primary care providers for urgent problems, an elderly physician sleeping in a back room, and a PA owning the whole shootin’ match. How’s that working?
In 2012, the most common condition seen in an urgent care center was an upper respiratory condition. The overwhelming majority of these are viral colds and bronchitis, with the occasional flu thrown in. We know antibiotics are worthless for these and yet in this urgent care center, an estimated 80 percent of the patients who present with respiratory symptoms receive intravenous Rocephin, a broad-spectrum antibiotic. Preloaded syringes of Rocephin are lined up on the counter each day ready for the daily stream of coughs, sniffles, and sore throats. Not only is this bad medicine, it perpetuates the overuse of antibiotics that has contributed to widespread bacterial resistance to these drugs, in addition to more frequent side effects.
Each center may see up to 120 patients in a day, limiting patient visits to no more than a few minutes. Patients are limited to discussing the problem that brought them in, period. There is no time for going over anything else. There are no “Oh, by the ways…” The moment a problem becomes too time-consuming or complex, the patient is referred to the nearest emergency room. The NPs and MAs are paid a bonus for every patient they see beyond a certain minimum, placing a premium on moving patients through as quickly as possible. I don’t care who you are or how smart; you simply cannot provide quality medical care to this many patients in a day. Things will get missed or overlooked. Mistakes will be made.
One of the ironies of this medical/business model is that it apparently provides high patient satisfaction. Many patients feel they get more face time with the providers at the urgent care center than from their usual primary care physician. This is a terrible indictment of the status of primary care, with primary care physicians spending much of their patient care time entering data into electronic medical records, and employed physicians being offered incentives to see as many patients as possible in a fixed period of time.
Urgent care centers were not intended to function in this fashion. The first ones, in the 1970s, were founded by emergency medical physicians who saw a need for walk-in clinics without sacrificing the qualifications of doctors. Today, patients at an urgent care center are unlikely to see a physician. Instead, they will see a mid-level provider who may have less clinical experience than most medical students, and much less education.
The expanding scope of practice of mid-level providers (NPs and PAs), who can now practice independent of a physician and oversee even less trained MAs, along with the profitability of these centers, ensures that nothing about the situation will change in the foreseeable future.
When you go to an urgent care center, you should know what you are getting. What you don’t know can hurt you.