Urgent Cares, Eds, Reliabiliby, Reputation, and the Rise of New Paradigms
Several weeks ago I happened to be walking down a street in Brooklyn, NY, when a downed sign tripped my step. Likely it was my clumsiness, or my age, that were the big contributors to that fall, the result of which was a cut lip and profuse bleeding. Getting back to my room with applied pressure, it was clear some stiches were needed. The wound was not terrible, though somewhat complex it did not cross the vermillion border, so repair by a competent ED physician, or an experienced PA working under one, seemed the best bet. No plastic surgeon needed (as yet). I decided on going to an UC, to save time, effort, and avoid the crazy waiting rooms of larger NYC hospital EDs.
It was a Sunday, around 1pm, and Google showed four or five urgent care centers, all open for a few more hours, within several miles. That became my plan to get this minor boo-boo fixed. If I’d have had two-hands, an assistant, and some equipment, I’d have done it myself. But no. So here I go, to the other side of the doctor-patient virtual fence, becoming a patient, an ED doc in an environment familiar but unnatural to him.
Of the UCs in the area, two were owned by a doc I’d known for decades; I kept looking. The other three advertised "a full staff of 13 (or in another case 15) board-certified emergency physicians on staff and one always on duty," "we can handle anything," etc, etc. Bingo. So I picked one that seemed closest, just over the Brooklyn Bridge, called to be sure, and got the message "we are open ‘til 6pm on Sundays, and waiting to help you," got a cab, and headed there.
The sign on the door said "closed today." What? Really?! Okay, will deal with it. So far I’d used nearly a full tissue box compressing the wound. Got another cab, asked the driver to head back over the bridge, and called UC#2. After describing the small, relatively simple, facial wound to the female on the other end of the phone, she said "let me check with the provider on duty." Note: no mention of "the provider on the premises." Several minutes later she returned and said: "I’m sorry, we cannot handle face injuries here, you will have to go to an emergency room." Seriously!? I wanted to say "Can I use a few ccs of xylocaine, a needle-holder, and some suture? But they did not know me from Adam, and not to be fully beaten down from the UC concept that I have supported for decades, I tried the third on my list, telling the driver I’d give him a target address as soon as I knew it. "Sorry," the UC desk person said, "We have no one here that can handle a laceration." Where am I? Sub-Saharan Africa? No, I’m in Brooklyn – NYC. So I bit the bullet and went to a not-too-distant large metropolitan hospital, whose director I’d known for years. The waiting room was not overwhelming, I was cared for in minutes, and out in under an hour, of which maybe 20 were taken up with wound repair itself. On the cab-ride back, and the in the hours and days afterward, this experience left me scratching my head, and thinking.
Reputation and Reliability
Urgent Care centers have skyrocketed into the US healthcare scene, and not without reason. They promise things that EDs cannot fully guarantee: short waits, quick face-to-face with a provider, and decreased cost and complexity. What became clear to me, as a proponent of this development, is that the UC, as a site of care-delivery, has not yet matured. Hmmmm. Now, what would such maturation look like?
For one thing, there would be recognition that reputation for being reliable (at least for the key components of immediate care) is an essential piece for success of the whole concept. Independent UC have a need to promote a reliability reputation not only for their own success and survival, but also for all others. That is, if, for example, a person goes into an ED in Newark, NJ, and has a downright terrible experience, then when later in, say, Los Angeles, needing ED-type care, that previous terrible experience, a full continent width away, will inform the real-time choices that person makes. In the same way, experience in an UC on Long Island will inform the consciousness, and care-choices of a patient who may need care later in Georgia or Florida. Thus, UCs are not independent of one another with respect to reputation. This is especially so in these early years of the UC paradigm.
Fortunately an organization like UCAOA has an opportunity to impact the entirety of the emerging specialty by developing criteria that best-practice UCs work to meet. No, these won’t always reach full compliance. But operators of UCs should be aware that what they do on an individual basis makes a difference to all UCs. What happens in a UC does not stay in that UC.
And, while UCs have a spectrum of capabilities, from "free-standing" EDs to PA-only, the reputation of the entire UC endeavor pivots on reliable, honest, and dependable advertising.
No matter how one views emergence of UCs, its paradigm is new-kid-on-the-block in the US healthcare landscape. Welcome, for now, but needing some "getting-used-to."
UCs arose because of need, as do most elements of the healthcare system, from penicillin to fiberoptic intubation. In UCs case it was the complexity and difficulty of encountering an ED; the seeming failure of ED "fast-tracks" to actually be "fast" as their rooms were taken over by critical-side overflow; and the overlying gray-cloud of cost that EDs seem unable to escape.
At this point in the infancy of the UC paradigm, those who operate them should be keenly aware of the importance of building reputation. And, as noted before, the communal reputation each UC generates for all others.
For me, at this moment, if (when) I get crushing sub -sternal chest pain, I know where I will go, and it will not be an UC. If I fall and cut myself again, or if I develop bronchitis/pneumonia, it will be a head-scratcher (unless my hand is bleeding badly). While, minor injuries, wounds, lacerations, and upper-respiratory and GI infections form the bread-and-butter of UC operations, not all people understand these distinctions. What they do understand is that UCs generally promise quick in-out, dependability, but with a more limited door-open time than EDs. I think that UCs would want me as a paying, insured, patient, who generally causes no trouble. Maybe I am wrong. But I am hoping, for my sake, and for the sake of my family, that those I love are able to rely in the future on those places that are opening up all over the map. If real-estate uses the three Ls, UCs should be thinking the three Rs (reputation, reputation, reputation).