Caution always in order about Walk-In/Urgent Care Clinics

Words of caution are in order about the emerging fad of Walk-In/Urgent Care Medical entities, especially those in retail establishments such as the newly opened one in Springfield's HyVee supermarket.

In the world of medicine, "convenient" rarely translates easily to "good" or "proper." Free standing "walk-in" clinics and so-called "urgent care" clinics feature encounters that are usually full of contrivance and charade.

The probability that a patient will have his or her illness (or set of illnesses) correctly diagnosed and treated is actually remarkably low; perhaps no better than by coin-flip chance alone.

Patients the vast majority of the time will still recover completely from their maladies; but they will do so in-spite of or despite whatever attention they receive in one of these clinics.

I will illustrate this by pretending that I, myself, am the provider at one of these walk-in "shoppes." And let's assume that I am a competent one at that, although there usually no such a guarantee at this type of clinic.

Let's use the common example of an adult with a sore throat who has the expectation that some treatment, an antibiotic, say, must be necessary. As the patient and I are unknown to each other, I am unfamiliar with the patient's medical history and this setting is not suitable to review everything about the patient, even though that is really what is necessary to accurately assess and plan what might be best for the patient. The patient is in a hurry-- it's a walk-in clinic after all, not the Cleveland Clinic-- and the patient neither expects nor wants a thorough review. The patient likely does not want a thorough physical exam either. And, if I were to do such a thorough review and exam and make further recommendations based upon it, the patient will likely be angry because I have confused him or her by making complex what they anticipated would be simple; especially if I do not do the anticipated tests and do not prescribe the anticipated meds-- an antibiotic, at least; or at least a bit of a narcotic for the pain or cough. In this setting, the patient's mindset is to withhold from me much of his or her medical history, as the patient thinks it will be irrelevant and will make lengthy what he or she expects should be a quick and expedient encounter.

I will also likely jeopardize the patient's relationship with his or her personal physician, with the uninvited intrusion of my own assessment of the patient's medical status-- perhaps indiscretely usurping away the authority of the personal physician, implying perhaps that the personal physician may be wrong in certain elements of the patient's care. Too many meds possibly? Unsubstantiated diagnoses? Overlooked symptoms and findings? How much should I reveal to the patient of my thoughts about his or her medical status? It will always be too much or too little, never the right amount.

And what, then, should I reveal to his or her physician? Should I send the physician a copy of my note in which I imply that the patient has not been cared for properly? If I let all that go, I will be angry at myself. If I reveal to the patient and the patient's physician what I really think, I risk to antagonize them. I believe all of us would agree to call this a "no-win situation."

Of course, if I am the type of provider who usually works in one of these clinics, I "don't go there." I just do the bare minimum. Narrow focus. Obvious diagnosis. Prescribe something, anything. Put on a good show. Make the patient happy. Nothing bad will come of it. But, just in case, always suggest a follow-up visit if things don't go well.

Well, for better or worse, I personally am not this kind of physician. I am an internist. By definition, we internists are supposed to be thorough. Before I find myself even further worked-up with criticism of what has become an institution everyone seems to have fallen in love with, I will offer up my personal solution to the conundrum of these more-ubiquitous-than-ever Walk-In/Urgent Care Centers: I suggest that I, myself, should never again work in one; and that folks should be very reluctant to go to them.

One further word: In the example cited by the SJ-R of the woman who went to the Hy-Vee Walk-In Clinic, she was pleased to receive an antibiotic for her presumed diagnosis of "bronchitis." Just for the record, medical science for over a decade has made it quite clear that an antibiotic is NOT indicated for bronchitis. The patient, therefore, received a medication she almost certainly did not need, and one that has serious potential side-effects. My guess is that she also received the wrong diagnosis.

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