Urgent Care and antibiotic overuse

Urgent care for health care is a growth industry and is in some ways at least hurting the health of our population. Wired had a good summary of the situation that I thought worth sharing.

I don’t understand why doctors are prescribing things that their patient doesn’t need, just because the patient asks for them. Isn’t there some sort of oath or standard or whatever that doctors take to not do that?

The pressure on doctors is incredible. Say patient comes in with a cold. I explain to them that this is viral and that antibiotics will not help. They argue with me that their last doctor (UC, etc) gave them an antibiotic the last time they had this and it was better in 3 days. I explain that their symptoms will be better in 3-7 days without antibiotics. They complain that they are traveling/getting married/have a big event in 3 days and must have antibiotics immediately in order to get better. I explain that it will make no difference. I then spend another 5 or ten minutes explaining the signs and symptoms of bacterial infections and assure them that if the symptoms are not gone in 7 days they can call back and I will consider antibiotics depending on their symptoms and not make them come in for a visit and have to pay a copay. 48 hours later I get a call that they are not better yet and need antibiotics which “always work”. I explain again that the symptoms have to run their course. The next day I get a note from the local urgent care that the patient was seen and given antibiotics. The patient then leaves an online review stating that the doctor refused to treat their infection and that they had to go to urgent care where they finally got the antibiotics they needed and as soon as they took them they felt better and their symptoms were better within 2 days (note that this is when they would have gotten better anyway).

So:
-the doctor gives in to the patient and gives them antibiotics=10 minute appointment, happy patient, good reviews.
-the doctor sticks to good medical care=20 minute appointment, multiple angry telephone calls, unhappy patient, bad reviews

Can you not see why many doctors choose option 1? When you are trying to run a business, it is hard to work harder just to make your customers unhappy.

The same not-taken-anymore oath says “I will not give poisons to people” and “I will not provide abortifacients to women”. Nowadays we know that whether something is a poison or not is basically a matter of dose, and abortion is considered a right in many countries.

When medicine is perceived as something you do “to get rich” rather than “to help people”, doing things that mean higher income is pretty much the point. When it is a business rather than a service to society, “the customer is always right” is a business model many people consider perfectly valid.

Yes, yes there is but IF a particular provider is more concerned about getting in and out of a room quickly while maximizing their patient satisfaction scores then a quick script is the ticket. Those telephone medicine services are, IME, an order of magnitude worse even.

Explaining why a script is not needed takes time. Oh once there is a provider-patient relationship not MUCH time but some. In the office setting it is not hard. If I give the spiel once it is quick the next time. And in the established relationship setting there is already some trust established, both ways - I (general pediatrician) can tell a parent that the not too bad ear infection I just diagnosed will, most of the time, get better without medicine, discuss comfort care, and give the option of calling for a script if it instead gets worse over the next 24, no need to come back in. They will most often believe me because they know me and if they call the next day I’ll believe them. The walk-in clinic provider does not have that.

Not excusing the providers bad medicine but the convenience care model does set it up.

FWIW I review my department’s patient satisfaction scores and have reviewed our members prescribing patterns as we work on antibiotic stewardship - in real life the docs with the best antibiotic stewardship end up with the best patient satisfaction scores and are usually also highly productive. Perception of what is wanted and what actually translates into the most 5 out of 5 scores are not always the same thing.

I have had doctors write a script and tell me not to fill for 3 days. If I wasn’t better. I have never had to fill one yet. My doctor now is very strict on prescriptions of any kind. I appreciate his diligence.

Perhaps. But the customer is NOT always right. I can’t go and get chemotherapy just because I say I want it, can I? I can’t get morphine just by giving the doctor a bad review on Yelp, can I? What about “Doc, I have diabetes, I need insulin!”?

Why are unnecessary antibiotics treated so differently?

If I have something that tests cannot determine is definitely viral or bacterial, and the doctor is up in the air about it, my PCP will usually say what Psychobunny says: call in 3 days (two if there is a fever that has not gone away), and I will prescribe antibiotics if your symptoms have NOT IMPROVED AT ALL. She trusts me to be honest, and she knows that I understand that antibiotics do not help viral infections. No second copay because I had to go in twice.

However, if something acute flares up, say, over a 3-day weekend, and I end up at an urgent care clinic, first, I probably already suspect a bacterial infection (like a UTI, or if it’s upper respiratory, I will be running a significant fever to be at an urgent care clinic), but aside from that, if it’s something the doctor thinks is kind of a coin toss bacterial/viral, she’s likely to give me antibiotics, because urgent care doctors do not have the leeway to say “Call me in 3 days if you aren’t better, and I’ll prescribe something.” They have to prescribe it NOW, or I will get charged another co-pay, either there, or at my PCP’s. Now, the urgent care doctor can hand me a paper Rx, and say “Wait three days to fill it,” but paper prescriptions don’t happen much anymore. They like to do it all online. So she can say “Wait three days to start it,” but at that point, I’ve paid for it, and she know what most people would do if they got better in two days: save the medicine until the next time someone in the household gets sick, then use it for them. Doctors really don’t like to think about that happening.

My daughter’s doctor has done the same, although, in her case, I have had to fill the script on occasion.

But the current oath states not to just give people drugs that you know won’t work or to use the pharmacy like you’d launch a parts cannon and a car with a rough idle. It states "I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism. "

Getting unneeded chemo will make you sick for no reason, getting morphine can make you sick for no reason, getting insulin can make you sick for no reason. Getting a round of Zithromax probably won’t kill you in the near future. Yes, superbugs, but you’ll be alive and healthy when you get the superbugs.

Last time I was in an urgent care for a suspected UTI, they test didn’t show anything and she couldn’t decide, for sure, if it was or wasn’t something (not a ton of symptoms, but do have a history) so she gave me the option of doing an antibiotic or skipping it. IIRC, I took the script with the intention of waiting a day or so. I never filled it.
But that’s still very different than if she had known for sure that a bacterial infection wasn’t present or if she was in and out and I left with a script in hand 5 minutes later.
She did have a reason to believe that my test was gave a false negative.

IANA medical provider, but I did work for a large urgent care/occ health company recently.

My suspicion isn’t so much that they hire incompetent doctors, or that they’re entirely unmanaged/unregulated, but that the transitory nature of the urgent care setting makes a lot of them opt for a more patient-centric approach than a primary care doc might. They know that their urgent care patient is likely to show up once and expect to be treated successfully in that one visit. So they’ll prescribe antibiotics in the off chance that their patient’s sinus problems are actually an infection, because it won’t hurt them if it’s not, and they’re likely to come back for future visits if they feel like they’ve been appropriately doctored.

I don’t know exactly how that fits into the clinical standards for the company though; the clinicians kept that kind of thing close to their chests, although I do know they put a lot of work into that stuff and trying to distribute it. I do know that there’s a sort of weird reluctance for supervisory doctors to second-guess their subordinates’ diagnoses and treatment plans, kind of a professional courtesy gone a little astray. So those standards aren’t always observed or enforced like they probably ought to be, except in the cases of occ health where the payers (worker’s comp insurance carriers) made noise about it.

A primary care doc, OTOH, already has that relationship with their patients and will often make them call or come back if symptoms don’t improve, and will do stuff like e-prescribe based on a phone call, or write scripts to be filled at some future date if things don’t improve in situations like that. I suspect that urgent care doctors are reluctant to go that route because there’s a good chance they’ll never see that patient again.

It definitely seems like a real problem, as is the overall problem of antibiotic resistance.

I was just reading a species of vancomycin-resistant bacteria in hospitals is actually becoming resistant to the alcohol in hand sanitizers, too.

So maybe the bigger and more important question is: how can we set up our systems / incentives so that this is LESS of a problem?

Are there other countries with notably lower antibiotic resistance problems? Are there policies proven elsewhere that we can adopt?

This is another great argument for universal single payer health care. If you have ONE standard of care and protocols it helps cut down on dumb shit like this because billing for antibiotics because a patient has a cold means the healthcare provider doesn’t get paid for that–that’s a freebie because it doesn’t follow the standard of care protocols. If you bill for something that’s a tossup, that will get paid because the protocols allow for that. UHC means a lot less doc shopping to get a desired result, and those ignorant patient reviews won’t matter a lick. Follow the guidelines, you’re golden, you get paid. Prescribe antibiotics because little Sally’s obnoxious parent screams for them to fix little Sally’s runny nose and you get zip for that interaction. I think that would fix itself right quick.

Can you prescribe a course of placebomyacin?

I’ve been to countries where antibiotics are the equivalent of over the counter, not sure why we are so concerned about possible overprescription in a place where it is many times harder to get.

And I have been to a urgent care where they refused antibiotics for the above reasons, and had to go to my dr who prescribed them, now in a much stronger dose because the urgent care didn’t do their job and time have passed.

And illustrating the narrative ^

Yes over the counter antibiotic use (and agricultural use) is a problem in the world:

Huge resistance issues in those countries. Greece and Romania in particular have major problems.

Auuuuugggghhhh!!!

There shouldn’t be such a thing as “leftover antibiotics”! I wish we could get it through to people that you take ALL of the prescription, or it doesn’t do any good!

I actually know someone who managed to kill her kid by giving her antibiotics until her strep symptoms cleared up, and then stopping them. The kid’s infection then raged out of control two days later, and she became septic. She was only two years old, and her body just got overwhelmed.

That, after the doctor, the nurse, the receptionist, and the pharmacist all told her to make sure her daughter finished the whole prescription. But nope, she, with her all mighty GED knew better.

I always tried to prescribe antibiotics responsibly. This means not giving them when clearly not needed, and not using an overly strong antibiotic when they would probably help.

A lot of this boils down to statistics. For things like sore throats and sinuses, their are good studies allowing me to tell the patient there is an x percent chance you will get better without an antibiotic.

I do sympathize with long waits and busy patient schedules. You can give an antibiotic with the advice not to fill it for x days or unless symptoms y and z develop. This is still educational, responsible and considerate of the patients concerns.

I’m not sure I follow. Are you saying that if someone presents with a cold and the doc prescribes an antibiotic that uhc won’t pay them? That seems oddly easy to game. Change the Dx from rhinovirus to [bacterial] sinusitis. Granted, if big brother is watching, more docs may not be as willing to do that, but it seems like an easy out. Besides, how often does a doctor actually do a test to be sure.

I’ve given a few people a lecture when they noticed me coughing/sneezing and said 'do you want some antibiotics? I have some at home"

I once had this really painful cough. It felt like shards of glass were being pushed up into my ear canal everytime I coughed, which was frequently. And my ears were starting to hurt, a lot. I was concerned that the cough was going to give me an ear infection.

I went to the doctor and voiced these concerns and requested antibiotics. The doctor did not concur and I did not get my antibiotics. I did leave her office with a prescription for codeine cough syrup. 650 ml of cough syrup. That’s a BIG bottle. It worked, I was not concerned about the incipient ear infection anymore. Or anything else.

I do think if I had walked in and asked for cough syrup the visit might have gone differently.