EPtalk by Dr. Jayne 12/27/18

The holidays tend to bring out the best (or the worst) in people, depending on whether you work in the customer service sector and how harried your clientele might be. Healthcare has become less of a vocation and more of a transactional situation, where the customer is always right and ratings drive salaries as much or more than clinical outcomes might.

Our urgent care practice is open 365 days per year, although some of the locations close on Thanksgiving, Christmas, and New Year’s Day if they’re within five miles of another site that is open. We used to have every location open on those holidays, but it wasn’t an employee satisfier and closing a portion of the locations made a huge difference for our teams and their families. For those who do work on the holidays, we have catered meals delivered the day before so that staff can at least reheat something for lunch or dinner that might be marginally more interesting than a brown-bag from home.

My holiday rotation put me on Black Friday this year and also the day after Christmas. I knew I was in for a wild ride this morning when there were 10 people waiting outside my door before I even arrived. The situation must have been even worse at other locations, because my scribe was immediately redeployed to another site to work as a patient care tech and another tech was pulled to a third location. Several of our sites broke the records for most patient visits in a day.

I’m always glad that we’re there to help patients, but the unpredictability of surge volumes can wear out a staff pretty quickly. We had some patients who weren’t happy about the wait time and a couple who stormed out of the office because of it. Those are always difficult situations and the team took them in stride, although it always leaves a lump in your stomach when you know someone was unhappy.

The holidays also brought out some examples of the challenges we face in trying to coordinate care based on the way that healthcare is financed in the US. I saw one gentleman who had a work-related injury that occurred last Saturday. He wasn’t able to be seen because we have a worker’s compensation contract with his company and no one was there to authorize the visit. The practice couldn’t see him on his personal health insurance because he had already declared it to be work related and it would therefore be denied.

He wasn’t willing to pay out of pocket, so he went back to work. He couldn’t reach anyone in the authorization department on Sunday or Monday and the office was closed on Tuesday, so today was the first day he could be seen. Although he had tried to treat himself the best way he could, I suspect that he’s going to have a poor outcome because appropriate care was delayed.

I had a patient who required some specific follow up and I wanted to contact his physician through the after-hours exchange. Usually to accomplish this I ask a staffer to call the practice, listen to the after-hours message and get the exchange number, then have them put out a page for the physician to call my cell phone. It can take an hour or more for this process to happen, and in today’s care coordination non-event, it didn’t happen at all.

When my assistant called the practice, they hadn’t switched their phone system over from the usual “we are unable to take your call” message to the “we’re closed, please call the exchange at the following number” message. There was no voice mail available and the patient said he had driven past the office and found it closed. Without an exchange number, we weren’t able to reach his physician or another covering provider.

I had flashbacks from my days as a solo physician when I was the person who had to make sure the phones were switched over. I would call the office before I left to confirm it worked. I sent a task in the EHR to have tomorrow’s team try to do the follow up, but I’m sure that physician’s office is going to be slammed with calls tomorrow and I don’t envy my colleague in trying to take care of it.

We also had a patient come in late in the evening for a preoperative clearance visit, only to find out that her surgery was scheduled for the morning. Good thing that all of her labs were normal and her medical history didn’t have any concerning elements or that surgeon would have had a surprise on his schedule tomorrow. His office was working today, however, because they had called the patient and let her know that they hadn’t received her labs and x-rays, which prompted her visit to us.

We did see some genuine emergencies, including a patient who fell carrying a glass ornament that caused a fairly serious laceration when it broke and a patient with dehydration due to foodborne illness. We also saw some self-inflicted damage, including someone who was seriously ill after trying to “cleanse toxins” with a recipe she saw on the Internet. What she did was to partially cleanse her body of electrolytes, which we were happy to replete. Another gentleman had a raging fever, shaking chills, and poor oxygenation after failing to adequately treat his bacterial pneumonia with a vitamin B12 infusion given at a local spa.

We had two family members who were waiting with patients and decided to be seen “while we’re here.” They didn’t have urgent issues, but figured that since they were waiting already, why not? Neither of them had tried any over the counter or home remedies and both had minor problems that could have been treated for less than $10 at the drugstore. Convenience is king, however, and they both left with prescriptions so that insurance would cover it rather than spending the money out of pocket. They’ll also generate multi-hundred dollar urgent care bills.

It’s moments like that which become a bit depressing, when you are silently screaming that there is a patient in the room next door with an ornament shard stuck in their body, and instead of dealing with it, you’re writing scripts for athlete’s foot and cold sores. We also had patients themselves adding on medical problems after check-in, including one who wanted refills on all her maintenance medications while she was there for an ice-skating related fracture. The reason: “My doctor went on vacation the week before Christmas and never responded to the refill request.”

I felt sad for the nonagenarian who hasn’t felt good in a decade and whose chief complaint was, “I used to climb 14,000- foot mountains and now I’ve felt crummy for a couple of years” and who was brought in by his daughter. There’s not a lot we can do about that at the urgent care other than to offer sympathy, rule out any life-threatening issues, and arrange follow up care. I was grateful for the occasional strep throat visit or sinus infection and even the fractures since they didn’t involve family disharmony or complex psychosocial issues. I’m privileged to have elders in my own family who are generally in good health, and based on what I see at work, I don’t take it for granted.

There’s virtually no consulting work between Christmas and New Year’s, so I’ll be back in the trenches again tomorrow and then over the weekend. Let’s hope for primary care docs who have their phones set up, offices that are open, and sidewalks that aren’t slippery. My New Year’s wish is that the folks who concocted the influenza vaccine nailed it and that everyone has a happy and safe 2019.

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