Going to a new place for convenience

My family likes to go to Primary Restaurant for great food. We know the food is high quality and the chef takes special care to make everything just right with healthy ingredients. The staff gives great service, always making sure we have what we need. Because there's always room for improvement, they encourage quality development and the restaurant staff works to make things right to the best of their ability if a problem is identified.

Image source: Wikipedia

But one night we decided to go to Convenience Cooks. We were hungry and Convenience Cooks was on the way home. Were we starving to death? No. We had food at home we could have eaten, but Convenience Cooks was, well... convenient. Their menu was limited compared to what we are used to, but we were able to order something that was decent. While we were waiting, I decided to call Primary Restaurant to see if it was a good choice or if we should leave and go to their restaurant. They said since I made the choice and was already waiting, I should just stay at Convenience Cooks. The food wasn't the quality we were used to, but we ate it. I had second thoughts at the end of the meal, so I called the Primary Restaurant to see what they thought. The staff who is usually so helpful wasn't of any use helping me decide if what we ate was good for us or not. Since none of us felt satisfied and left still hungry, I feel like Primary Restaurant should deliver food to our home, but they refused. They said we should go to Primary Restaurant to eat if we want their food. Why? I already paid Convenience Cooks and had most of a meal there. Weeks later I get a bill from Convenience Cooks and am surprised about the cost of convenience, so I call Primary Restaurant to see if it's usual for Convenience Cooks to bill added fees.

In another scenario, you really want a good BBQ. Primary Restaurant specializes in All-American food, but don't offer slow-cooked BBQ, so they refer customers to BBQ-R-Us. But BBQ-R-Us is busy and requires reservations. Since you are used to same day seating at Primary Restaurant, you ask if they can get you preferential seating at BBQ-R-Us. After several phone calls back and forth with staff at each location, you realize you can be put on a waiting list, but no one was able to change your initial reservation. When that time finally comes, you enjoy the ribs, but leave with questions. Instead of asking the BBQ specialists, you call Primary Restaurant to ask if you should have gotten the burnt ends or the ribs. Even later you call Primary Restaurant to complain about the bill you got from BBQ-R-Us. You were surprised that the creamy corn was extra and they charged a seating fee.

Most people can see just how crazy it is for a restaurant to "fix" the problems with quality, cost, or service at another restaurant, yet many (MANY) people want their primary care physician to do just that after trips to convenience urgent cares or after we refer to a specialist. The scenarios above are based on real phone calls about medical care.

Convenience Cooks = Urgent Cares

I'm sure I'm not alone when I get frustrated at the number of calls asking me to give an opinion of treatment received elsewhere, or to fix a problem that wasn't fixed at an urgent care. I am glad that patient families feel so comfortable with my office that you will call to ask for help, but if I am not a part of the evaluation, I can't help.

Many problems seen at urgent cares can wait. I know it's easier to get your child in tonight so they can maybe go to daycare/school tomorrow, but many of these things are viral and just take time. Even if it's strep throat and they start an antibiotic at 8pm, they can't go to school in the morning. If you would have called my office before going to the urgent care (or looked on our website for advice), chances are the issue could have waited until office hours by using some at home treatments to make it through the night. The cost savings of staying out of an emergency room or urgent care can be substantial with many insurance plans. And my office would be available to help answer any questions that arise from that visit. (Note: sometimes when the symptoms change we still need to see a child again, but we are more likely to be able to help over the phone if we were the ones who saw the child than if they were seen anywhere else.)

If your child was having an issue that did need to be seen ASAP after our office hours, we would have referred you to an urgent care that has quality pediatric providers we trust and sends us a written report of what happened. Even with that, sometimes we need to see a patient on follow up to ascertain if a treatment plan is working or if it needs to be changed.

If you call us because your child is having an allergic reaction to a medicine someone else prescribed, we will tell you to call the place that prescribed the medicine. We cannot manage what someone else prescribed. Often we hear that "they're not open yet" or "they don't do phone calls, they want us to come back." Sorry. We will want to see your child before we treat him for this issue.

BBQ-R-Us = Subspecialist Referrals

As for specialist referrals, I know it's hard for people to wait for appointments, but I really can't get people in any quicker than a schedule allows. If it is a real emergent or urgent need, I can talk to the doctor to see options, such as admitting to the hospital so they can be consulted, or having someone go to the ER, where they might stop by to see the patient. But usually it isn't really that urgent from a medical standpoint, and waiting for the appointment is just what happens in the specialist world. I'm not saying that's a good thing, it's simply reality. Please don't beg me to call them to get you in sooner. I cannot invent time and I can't alter their schedule. Despite what the scheduler tells you, if the primary care doctor calls the specialist, the specialist rarely can get the appointment changed. I've done this frustrating scenario many times-- often when I really want the child seen sooner than scheduled. Unfortunately, it usually doesn't significantly alter the appointment time.

After your appointment I cannot tell you if the treatment plan they propose is the best for your child. Once I refer, it is usually because it is out of my knowledge base and needs specialist care. I can learn along with patients, but I rely on the specialist to know the latest and greatest in their field and they can give better advice than I can. I also don't like to "step on toes" if I refer. If they are driving the bus, they need to drive. Back seat drivers can cause problems on the road.

Expect higher fees any time you use a hospital based facility, whether it's for an office visit, a lab, or a procedure. They not only have charges for the physician's time, but they have facility fees to cover the costs of running the hospital. Of course the primary care physician cannot affect the charges incurred at any other clinic or hospital. We recommend researching costs prior to care, but we know that this is very difficult unless you know exactly what will be done at every visit. We cannot tell you what another physician will do... I can't even predict what I will do at a visit if you call me ahead of time. If your child has a fever and cough, I might send you home with at home treatment instructions without any expensive tests if the exam supports that. I might order labs or a CXR, prescribe a medicine, or admit your child to the hospital for treatment if the findings support that. It is hard to anticipate costs, and that is a problem with our healthcare system. I know that, but it is not in my control to fix that. We try to help by keeping a list of all our most common charges in the parent book in each exam room, but that doesn't help plan before the visit. I understand how that's frustrating, but I can only help with what is in my control. I cannot control how our billing and insurance system works and another office's charges are in no way under my control.

Urgent cares for routine illnesses ... yes or no?

photo source: Shutterstock

Every day I review reports from urgent cares that my patients visit outside our office. I know many parents go because they are worried about their sick child and want them to be seen immediately.

Some may not realize that our office has extended walk in hours ~ we are often open when they go to these urgent cares.

Or they might simply find it more convenient to go to the corner clinic near their house.

Other parents do not want to miss work (or let their kids miss school) so they go after hours to an urgent care clinic (despite our extended hours).

Sometimes there is a financial incentive for the family with a lesser copay at a walk in clinic because of the insurance contract with that company. (Don't get me started on the reasons that makes my blood boil...)

Urgent cares and emergency rooms are designed to quickly evaluate and treat patients with significant illnesses and injuries. They do not have the luxury of follow up, so they tend to err on caution and do more labs, x-rays, and prescriptions than primary care offices. This not only exposes kids to more medications, excess lab draws and x-ray radiation, but it costs parents more money. (Even if your plan doesn't require you to pay for that specific test, you pay for it through your premiums.) Although urgent cares cost less than emergency rooms, many are finding that costs are still well above those at a primary care office.

Most often visits are for things that could have been taken care of in the primary care office without all the added tests and treatments. A common visit to an urgent care is for ear pain. Often when kids are diagnosed with an ear infection, they leave the urgent care with a prescription for an antibiotic despite the fact that the large majority of these infections are caused by a virus and antibiotics are not effective against viruses. I suspect that part of the reason patients leave with a prescription and fill it right away is the urgent care wants to get patients in and out quickly. There's an ear infection and it's easier to just write a prescription for an antibiotic than it is to explain why it is okay to treat symptoms at home without a prescription for a few days first. They also don't have access to the past medical history and vaccine records, which can impact treatment choices, so they must be more cautious and treat.

And parents are happy. They "got something" for their visit.

Another common ER or urgent care visit is for fever or cough. At these visits they often get a chest x-ray and labs.

And parents are happy because "something was done" at the visit.

At the primary care office labs or x-rays might be done on occasion, but it is less typical. A good history of illness and physical exam usually can identify the most likely diagnosis. Instructions on how to manage the illness and when to follow up can be discussed.

And yes, this does cause less patient satisfaction sometimes because they didn't "get something" for their visit. What they got was an assessment, a diagnosis, a treatment plan of things to do at home to treat symptoms, and instructions on how to monitor for worsening of symptoms. Nothing tangible, but very worthwhile!

Unfortunately, many parents see excess testing and treatment as good care and don't realize that it is the inexperience of the provider who is over treating. An experienced pediatric-trained primary care provider would not need all this testing to be comfortable making a diagnosis and watching the patient over time without prescription treatments.

Even a provider with years of experience in an urgent care setting does not have the experience of watching a patient over time without interventions. They never get to see patients get better on their own. They never get that opportunity to learn from their patients. They learn in training to evaluate and treat, then send patients out the door (or in for admission). That's what they do.

A big issue I alluded to above is patient satisfaction. Urgent care and emergency room physicians and midlevel providers are often under pressure to make patients happy, which includes doing tests and giving prescriptions ~ after all, that's what the patient paid for, right? {sarcasm} 

My concern is that higher patient satisfaction scores are NOT associated with better care. Conversely, they have been associated with higher healthcare costs, increased prescription drug costs, and even higher mortality. (The Cost of SatisfactionA National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality)

 Even my patients who have seen me for years might be uncomfortable the first time they leave with a diagnosis of ear infection and are told to NOT use an antibiotic right away. I don't get blood work just because a child started with a fever today. My patient families know me. We've developed a trusted relationship, so they listen to my advice. They learn that it is okay to not do labs or start antibiotics because I take the time to explain what is going on, what is to be expected as things progress, and what to look for if the child's condition worsens. They know how to contact me or the on call provider if needed.


I know that Americans enjoy the convenience of walk in centers at every drugstore. I understand that there are situations when kids are so sick they need to be seen after hours. But I also encourage parents to consider if waiting until regular business hours is appropriate for whatever is causing their child to be sick. Never wait if it is a real emergency. But if your child can be managed safely at home with pain relievers, saline, humidifying the air, massage, rocking, or whatever fits the symptoms, please use your child's medical home when they open. There your child will be well cared for, records will be complete at the primary care office, and there will be less over testing and treatment.

I have blogged before about the benefits of going to your medical home  and when to see your PCP. I continue to stand behind the idea of patients going to their medical home for most visits because I feel you get better care and more personalized service, even if you see a different provider within the office. We have the ability to update your child's records, see past treatments, know your child's immunization status and have record of any allergies. We have the luxury of having you follow up so we know if things resolve or if further evaluation and treatment is needed. We don't need to order every test and treatment on the first visit, because most of the time they aren't needed. We might ask that you bring your child back in a short time to re-examine and see how the symptoms change. (For more on the value of repeated exams, see Evolution of Illness.) We will walk you through your child's illness if you come to us!

March 2014 Update: For an interesting read on how some doctors must overprescribe to get high rankings, see Patient Satisfaction is Overrated.