ER, Urgent Care or medical home was-->Re: AAFP president's response to an Emergency Medicine News editorial

[Guest guest]

Straz,

Your post brought up some interesting thoughts for me and how the world comes across depending on what fence we are looking over. I practiced (and was medical director) of a large urgent care center for 4 years.

Your example below uses the holiday season as an example. Our busiest day of the year in urgent care, year after year, was always December 26th. I do not recall ever holding that against the primary care providers. I always considered this service to be one of the reasons urgent care existed----to let the amazingly overburdened primary care providers take some real time off. (One of the true bonuses to working in urgent care was that when I was not working, I had no patient responsibilities.)

You do touch on one of the solutions and that is the doctor-patient relationship, where I teach my patients when urgent care is needed and when not. Also, once they know they will be able to see me when I return from my very occasional retreat from the constant ongoing responsibilities, they do not seek out urgent care.

Because of my rural location, the two ED's and the one urgent care all know that I never send a patient to them without calling and giving some form of report. If one of my patients does show up during the week without my usual phone call preceding their arrival, they know to tell them to call my office and see if they can get in (they always can). They help to reeducate my patients on proper expectations and how to access the system.

In my ideal world, emergency departments would be for true medical emergencies, including MI, motor vehicle crashes, pulmonary emboli and other unpredictable life threatening events.

Urgent care would be for;

1. -those individuals who choose not to engage a personal physician (I remember seeing lots of truck drivers, etc...with tooth abscess, etc who did not have a permanent residence, therefore no " medical home " ),

2. -appropriate referral to the ER after recognition of a true, life-threatening emergency (I asked a patient at urgent care one time, as I arranged her transport to the ER, why she had come to us having her third heart attack (yes, the signs were identical to the prior two MI's) when she had driven past TWO emergency rooms to get to our location---her response " you guys are nicer here and I know I will be taken care of right way! " Sigh.)

3. -entry way (referral point) into a medical home for those who, prior to their recent pneumonia, thought they did not need a primary care physician.

4. -simple emergencies, like broken bones and lacerations, that require some significant overhead to maintain the needed equipment, (like x-ray capability, all the padding and equipment for splinting correctly, sterilization of equipment etc.---yes, I can still make a splint and I sew up lacerations when needed, even after hours when I can, but having a good working relationship with our local urgent care sure makes it easier on my patients to have the xray and the splinting all done at one location.)

5. -as a fall back for local solo physicians when life does not go exactly as planned. (I would have had to close my IMP last March with my back surgery if it had not been for the kindness and availability of our local ERs and our one urgent care. I could not afford a locums and my local back up had morphed into a mega-hamster-wheel). I called our ER's and urgent care the day prior to my surprise surgery (my surgeon gave me 24 hours notice) to let them know what was going on with me. I offered to dial up my office records from home to provide any information they needed to appropriately care for my patients while I could not walk or think straight. They were happy to help and appreciative that I had called them. I then arranged for another solo FP to see any of my patients that needed follow up from an urgent care or ED visit. (He went out of business in November this year, darn it). Some of my local ortho friends also took up some slack for me as well. By working together, Durango managed to keep me in business and I am able to continue providing primary care to an area that is in desperate need of primary care. It is truly amazing what can happen when we all show each other even the slightest bit of respect.

My true dream is that all of we providers, of all different backgrounds, specialties, and slants on healing learn that we are all trying to help patients----and then act accordingly.

Happy last day of 2008. May next year bring us somewhat closer to our dreams!

Durango, CO

I agree with all the comments and particularly llyon, joanne and graham. The guy is obviously angry, but aren't we all in some way. That said, in my experience, the guy has a point. Although the 21st century accouterments (EMR, etc.) are nice, the central component and emphasis of the medical home should be the personal doctor-patient relationship. Although the members of this list serve are actively creating medical homes for their patients based on interpersonal contacts, currently this appears to be the exception to the rule in this aspect of family practice. In my geographical area of practice, a number of practices seem to be lacking this bond between the provider and patient. As a family physician who works in an open access urgent care and sees my own primary care patients, patients with acute illnesses who are traveling or have no local PCP, as well as the primary care patients of other practices when their offices are closed (and when they're open), I truly perceive a breakdown in the doctor-patient relationship in a number of the local practices. I don't want to " name names " ; but everyday, I see patients at 9 or 10 am who have an acute illness or exacerbation of a chronic problem who called their PCP and were unable to get same day appts. Pediatrics is just as bad, almost none of the local pediatricians have appts available after 3pm when a lot of parents pick up their children from day care or school and learn they are sick; and as both parents are working, they have a difficult time scheduling appts during " normal office hours " . I think this ER doc is seeing the same thing. I'll agree that the current state of the health care system and its effect on MDs is driving the tendency of medical offices to fill their schedules in advance leaving an inadequate number of work-in slots and providers to consider their " reasonable " availability to be only the " normal " business hours of their office referring patients at all other times to the urgent care or ER (as a UC doc, I have a bit of this attitude myself but I don't claim to be a medical home). But it isn't easy to focus your blame on the system when you are seeing 6 or more patients an hour on Dec 26 and 50% of them have the same dozen PCPs who have closed their offices from 12 noon Dec 24th (if they even opened that day) until 8am on Dec 29th and plan to do the same thing from Dec 31st until Jan 5th. This may sound like sour grapes as obviously my billings and income go up, but it's not easy to keep smiling as the hamster wheel kicks into overdrive. Finally, I believe there is a bit of unrealistic patient expectations playing a role in the demand for immediate health care for nonurgent problems as I really don't believe it's necessary for a patient with a URI for 3 days or even 2 weeks to expect to see a doctor on Christmas Day for treatment (though I admit that my employer is partially responsible for creating this expectation).

I hope everyone continues to have a happy and healthy holiday and wish everyone a joyous and prosperous New Year.

Straz

You know, we've actually been seeing a decrease in the quality of ED care in our area. Alice did a fellowship in critical care and worked ED for 10years so she'd know. We had one patient that came in for fatigue and I dont really know what else, but they ED didnt draw blood on her. Good thing we did. Very Anemic--to the point we got a call from Quest and had to call her and send her back to ER. Another patient had an infection on his leg that wasnt healing or something. They called. I hear Alice asking if they checked for mrsa (?) They hadn't. Guess what type of infection he had? But I'm sure the author of this rant & rave (which I haven't actually read, but i can read your comments) would prob. deny these incidents happened.

To:

Sent: Thursday, December 25, 2008 1:19:07 PMSubject: Re: AAFP president's response to an Emergency Medicine News editorial

i'm shocked, just shocked, that an ED doc would rail so forcefully andwith such vitriol against us stupid, lazy, no-nothing family doctors,and against doctors in general, trained nowadays. after all, we

didn't grow up the hard way, wading through the blood and guts of theknife and gun club, saving lives by shoving sharp metal objects intodying patients' orifices while slurping down caffeine by the gallon to

stay awake for another 36 hours at a time.but i digress.i would merely ask dr ED three questions: does he believe that amedical home or however he would name it, is a valid and valuableconcept? what would the well-functioning and efficient dr ED health

care system look like? are there any elements of our current healthcare system that would be incorporated into dr ED's system?dr ED is concerned about the failings of our health care system, andrightly so; i see many failings in it, too.

what solutions does dr ED have? it's legitimate to criticize; one'scriticism is validated by offering solutions. i'd like to hear dr ED's.LL------------------------------------