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Wednesday, August 13, 2014

The urgencies of care: here, there, and everywhere

The New York Times just devoted a particularly prominent portion of its rarefied real estate to the issue of urgent care delivery outside of its traditional domain. The article in question was housed in the Times’ “Business Day” section, and reasonably so. Julie Creswell, the author, referenced a market of $14.5 billion that is growing briskly. So business it is, and big business at that.

But it is, of course, also my business, and yours, because it represents an evolution in how so-called “health care,” or more correctly injury, illness, symptom and disease care, is rendered. On any given day, it could be you, or me, or someone we love who has need of this changing system. That invites us to ask: are the changes good? Are there associated perils?

Naturally relevant provisos will follow, but I can provide the basic punch line right away: the changes are indeed good.

Access to care is an important element in the quality of both health care, and the overall public health. All too often small problems neglected for a while turn into larger problems. Barriers to care propagate just such costly misfortune.

Even if everyone had a primary care provider, and of course not everyone does, there would be barriers to walk-in treatment. Some practices are able to carve out time for walk-ins, but many have patients booked from open to close. There is no place in such practices for the unscheduled laceration or migraine. I worked in primary care internal medicine for roughly 15 years, and none of my practices comfortably accommodated unscheduled patients.

The traditional alternative, of course, has been the emergency department. The liabilities of that approach are mostly self-evident. A laceration of a finger, or a recurrence of migraine, and the innumerable variations on this basic theme, are urgencies, but not emergencies. In any given busy ER at any given moment, there may be heart attacks and strokes; seizures and gunshot wounds. I worked for some years as an emergency physician, notably to support my family while completing my preventive medicine residency, and there were times when the place was packed with people trying to die in various ways all at the same time. My job was to prevent that, and that put lacerated fingers way down my priority list.

But that was likely poorly received by the unfortunate soul with the cut finger who waited five hours to get the requisite 15 minutes of care needed to sew it up.

The time-honored approach to this has been an area of emergency departments dedicated to less emergent need. The urgent care movement likely traces its origins to emergency department triage to either the main area of blood and guts, life and death; or the suite of exam rooms devoted to lesser crises. Put that suite of rooms for lesser crises in a space all its own and the urgent care center is born.

Triage is the essential matter here. One potential hazard of urgent care centers is that a true emergency could turn up at the door, and the resources on hand might not be inadequate to deal with that. All such centers should have someone capable of triage serving as the receptionist. That would allow for a swift redirect to an emergency department when warranted. Such cases should be rare, and efforts to educate the public on the distinctions between urgencies and emergencies should make them that much more so.

Another potential concern about urgent care centers is that they will tend to rely on the cost-effective care of so-called mid-level providers, namely physician assistants and nurse practitioners. I have worked closely with both PAs and NPs over the years, and this doesn’t worry me at all. My mid-level colleagues have mostly been excellent. Like all of us in medicine, they need to be acutely aware of what they don’t know, so they get help when help is needed. But that is just as true of us physicians. The scariest thing to me in all of medicine is the practitioner who thinks they know more than they do, whatever alphabet soup follows their name. The evidence is clear that much basic medical care, and particularly the kind of care that fills up urgent care centers, can be delivered very ably, and at lower cost, by non-physician providers.

So what we have so far is one potential liability: people could wind up at an urgent care center who really ought to be at a hospital. But without recourse to an urgent care center, those folks might just wait it out at home, where they would likely be worse off by far. Capable triage and efficient referral at all urgent care centers turns this liability into an asset.

Other assets are quite clear. Urgent care centers can reduce wait times and costs. They can let emergency physicians focus on emergencies, and primary care providers focus on the scheduled visits of longitudinal care. I think stand-alone urgent care centers are a growing trend for good reason.

But a focus on urgent care networks only in the context of historical “health care“ delivery is limited; they have the potential to go beyond it. I know, because I have been privileged to participate directly in one such innovation.

RediClinic is a network of clinics providing routine, sub-urgent care on demand. They are unique in many ways, the most obvious being location: they are housed in supermarkets throughout Texas.

The provision of sub-acute care in a setting as heavily trafficked and generally convenient as a neighborhood supermarket is rather innovative in its own right. But the RediClinic leadership had an epiphany some years ago about going beyond health care to the general care of health. The idea was to establish a clinician-guided weight management program that could be offered right in the very supermarket where clients would be shopping for food.

When this idea was brought to me, I loved it, and the rest is history. I worked with RediClinic to develop the Weigh Forward program, which has gone on to be the first weight loss program formally certified by the American College of Preventive Medicine. It is also among the reasons why RediClinic was recently acquired by Rite Aid, raising the prospect of rapid expansion of Weigh Forward into a program available nationwide.

I know this example best because of my direct involvement in it, but I can think of many others. Treatment centers for sport-related and orthopedic injuries might be housed in or near fitness facilities. Perhaps care for sleep disorders could be housed in or near mattress stores. Easy access to mental health counseling might prove both beneficial and cost-effective in high-stress worksite settings.

Increasingly, we have access to urgent and sub-urgent disease and injury care here, there, and everywhere. Done right, this is distinctly advantageous. But the next great frontier in health care is exactly that, the care of health, rather than the treatment of established disease. There is an urgent need for more of that as well- with a particular emphasis on the 6 factors known to be most influential on overall health and well-being: tobacco use, dietary pattern, physical activity, sleep, stress, and social connections.

Urgent care centers can also figure among the health care innovations that direct clinical resources to support lifestyle as medicine. They can and they should, because it is an area of both great opportunity, and considerable urgency—and everybody’s business.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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