A lot of people are using urgent care centers for health issues – and some are finding that the results are less than perfect.
An internal medicine doctor kicked off the discussion on a Facebook group, writing: “I’m curious if any patient gets anything besides Z-pak and steroids from Urgent Care. Does not seem to matter what the chief complaint is. Sometimes they may do doxycycline and prednisone.”
Another chimed in: “Last week someone I know had to go to an UC, and you guessed it/ Z pack and steroids for ‘stomach flu.’’’
As the winter comes on, colds, flu and RSV are starting their annual surge, with Covid rising in many places. Meanwhile, it’s hard to get a doctor’s appointment, either with a primary care physician or a specialist – and urgent care centers seem to be popping up everywhere. Sometimes that’s your only option to be seen by a medical professional outside of the emergency room.
So if urgent care centers fill a need, what’s the problem?
The staff of urgent care centers is probably not an M.D. or D.O. Staffs are 84 percent advanced practice providers, like nurse practitioners and physician assistants, according to an article in the Journal of Urgent Care Medicine. Doctors say that these less qualified clinicians often are in a hurry and may default to a kneejerk “here’s a Z-pak,” even if that’s clearly not helpful from a fully trained doctor’s perspective. Z-pak, Zithromax (azithromycin), is an antibiotic used to treat infections like bronchitis and ear infections; it is not useful for a viral infection.
First, definitions
For simplicity’s sake, we are talking about urgent care centers and walk-in centers interchangeably. Some clinics that label themselves as “walk-in” will see a patient who urgently needs medical care, while other “walk-in” clinics will not. To confuse things further, some primary care facilities take “walk-ins,” while some “walk-in” centers require that you call ahead. (More here.) For this post, we will generally use “urgent care” to refer to anything that is not in your regular primary care provider’s office, or not in the hospital emergency room, but a place where you can walk in or be seen on short notice with an urgent health issue.
A primary care doctor visit is often preferable, but more than 100 million Americans face barriers to getting primary care, a recent study found. This can be more acute in a rural area or in an underprivileged area. Primary care doctors don’t always have short-notice appointments, and emergency rooms promise a long wait and a whopping bill.
The vast majority of urgent-care visits are routine and without problems, which is one reason urgent-care medicine is growing so fast. According to the Urgent Care Association, patient volume at urgent care centers has increased by 60% since 2019, the Advisory Board wrote in February 2023: “Currently, there are a record 11,150 urgent care centers in the United States, with around 7% growth annually, U.C.A. said. Notably, this figure excludes clinics inside retail stores and freestanding E.D.’s. According to estimates from IBISWorld, the urgent care market will reach roughly $48 billion in revenue in 2023, a 21% increase from 2019.”
At the urgent care center, a physician assistant or nurse practitioner is often (though not always) under at least nominal supervision of an M.D. or D.O. This is true whether they are for-profit systems or attached to nonprofits like the local hospital system. An M.D. is likely to point out that the nurse practitioner or physician assistant has considerably less training, both in time (years and hours of education) and depth of subject matter.
The healthcare industry currently has a lively discussion about how lower-qualified people like nurse practitioners and physician assistants are doing work that would be better done by better-trained medical professionals. Many doctors won’t work in urgent-care clinics; pay is typically lower, and the owners will make more money hiring less-qualified and lower-paid personnel. And there are not enough doctors to go around — which can mean that mistakes happen.
To further complicate matters, the umbrella term “advanced practice providers” is roundly hated by some doctors, who suggest “non-physician providers.” Beyond that, the term “providers” is in bad odor with some. When someone writes “provider” on the r/Noctor subreddit, an automated response appears, reading, in part: “We do not support the use of the word ‘provider.’ Use of the term provider in health care originated in government and insurance sectors to designate health care delivery organizations. The term is born out of insurance reimbursement policies. It lacks specificity and serves to obfuscate exactly who is taking care of patients. For more information, please see this JAMA article. We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP.” Here’s a full thread on the r/Noctor Subreddit on that topic.
Doctors’ views
One doctor wrote: “I am a board-certified emergency medicine physician licensed in multiple states (mid-Atlantic and Midwest). Over the years I have had highly variable experiences with urgent care practices. For example, I had an urgent care in Wisconsin that recognized that the patient had severe sepsis and they gave intravenous fluids and appropriate antibiotics before referring the patient to me” in the emergency department, perhaps without being paid because the patient immediately went to the hospital.
“However, I have also had urgent care centers refer a patient to me for ‘rule out meningitis’ which would require a spinal tap. On examination, there was absolutely no possibility that the patient’s symptoms were due to meningitis. … The procedure they had requested was not only entirely unnecessary but also potentially harmful, not to mention very unpleasant for the patient.
“The running joke in my specialty is that urgent care exists to give everyone steroids and Zithromax. Unfortunately, we do see this very frequently, and inappropriate antibiotic prescribing has, over the decades, created very serious problems. I have had multiple patients who have died of infections that were resistant to every antibiotic we had in the hospital.”
A friend in the New York area told me it’s a two-week wait to see her primary care provider. She went to urgent care and got a Z-pak and some benzonatate for her cough. If it doesn’t work, she’ll have to get in line for a visit with her PCP two weeks from now – or go back to urgent care or the emergency room.
A New York area woman had an urgent-care visit on a holiday morning, when she was away from her home and her local doctor — though his office wasn’t open anyway. She got a diagnosis of a bacterial infection and a prescription immediately.
Diagnosis gone awry
The pandemic has affected urgent care in many ways, for patients and the advanced practice provider (A.P.P.) too.
“Before the pandemic, newly hired urgent care A.P.P.’s went through a training period alongside a physician or seasoned A.P.P. They were given time to learn additional procedural skills and how to form and work up a differential diagnosis in the urgent care setting,” the Journal of Urgent Care Medicine wrote. “The pandemic practically eliminated this ramp-up period for newly hired A.P.P.’s out of necessity to handle the massive patient volume.”
The article also noted that “patients per hour per provider” has become the metric for getting paid, which means that clinicians are rushed — even more so since the influx of Covid patients during the pandemic.
Not every visit is perfect. One doctor wrote: “6 year old boy seen in UCC for ear pain and fever. Told ears were fine and sent home. Continued to complain of ear pain, fever, refused to eat or drink. I saw him the next day and in fact his ears were fine. Classic strep throat on exam, large AC lymph node and +strep test. I asked mom what the NP said when she saw his blazing red tonsils. She said no one looked at his throat.”
Another: “Newborn infant 4-5 weeks old seen in UCC for rash. Told it was poison Ivy by NP. In a newborn. Mom wisely took baby to children’s hospital ED and diagnosed with herpes. Admitted. This is a life threatening error.”
Another: “I had a patient with sudden onset left ear pain after jumping into a swimming pool on vacation. Seen in UCC in Florida and put on amoxicillin for ‘swimmers ear’. (Wrong diagnosis and wrong treatment) Came home went to another UCC and antibiotic changed to augmentin. … Came in to see me now 3 weeks later with [perforated tympanic membrane, or tear in the eardrum] with a nice scab on the ear drum.”
Another: “My niece broke her shoulder at the growth plate. Went to urgent care. [Nurse practitioner] said no working x-ray so they told her to come back the next day (#1 wrong should have sent her to a location with working x-ray). Brought her back the next day, x-rayed her elbow but not shoulder despite request and put her in a sling (#2 wrong/almost opposite treatment for the type of fracture that she had). Went to Ortho because of intense pain – imaged, took off sling, immobilized to chest wall. Now well healed.”
Industry trends and history
The urgent-care industry is changing, with things like the primary-care shortage, the pandemic, financial incentives and economic changes driving a transformation from the old model to a newer one.
“Founded by emergency medicine doctors on a mission to keep nonemergent patients out of the ED, urgent care has been forced by changes in reimbursement policies to emphasize high productivity and labor cost savings — ultimately leading to overall fewer procedures and thus a lower acuity level for urgent care centers,” Benjamin Barlow, MD; Monte Sandler; and Alan Ayers wrote in the Journal of Urgent Care Medicine.
The drive for profits has changed the nature of the industry. But documenting any research on diagnosis errors or similar data is hampered by ownership.
“Privately owned facilities, which make up 70 percent of the urgent care market, are under no obligation to turn over information for research purposes,” Niran al-Agba, a longtime pediatrician, wrote in February 2022 a New Republic article, which described the death of a 4-year-old Texas girl who had been diagnosed by a nurse practitioner at an urgent-care center as having flu, but who was actually suffering from sepsis. She later died.
“One does not have to look very far to understand the reason for these facilities’ reliance on nurse practitioners and physician assistants: Doctors are far more expensive to employ,” al-Agba wrote. “An emergency physician earns an annual salary of almost $300,000 on average, whereas an N.P. or P.A. working in the emergency department commands less than half that amount, around $130,000 per year. … Urgent care facilities still charge patients as if a physician were present. The combination of cheap labor, high profits, and high demand helps explain the boom in urgent care centers across the United States, and particularly who owns them.
“Thirty-nine percent are owned by private concerns, either private-equity firms or other profit-seeking corporations. Thirty-one percent are owned by hospital chains or joint ventures with hospitals. Just 14 percent are owned by physician groups.”
“My view, obviously informed by my own training, is that while N.P.s, P.A.s, and nurses are integral members of the health care team, their role should be circumscribed: In primary care, emergency, and specialty settings, they should work under direct supervision. The Journal of Nursing Regulation, the official publication of the National Council of State Boards of Nursing, agrees that, under current conditions, N.P.s should not perform unsupervised care in emergency settings, regardless of state law or hospital regulations.”
Al-Agba is author of he author of “Patients at Risk: The Rise of the Nurse Practitioner and Physician Assistant in Healthcare.”
Viral pinkeye
Back to the stories: “Once, as a wee lad/first-year resident ER physician, I decided to stop by the local walk-in/urgent care clinic affiliated with the large system I was working for at the time (which I knew was staffed by NPs and did not have a great reputation.) I … was pretty sure I had a mild case of viral pinkeye/allergic conjunctivitis (certainly not bacterial as I didn’t have severe symptoms like discharge, eye crusting shut, etc.) … The NP who saw me didn’t even bother examining my eyes. After about a 30-second history, she asked me ‘what I thought was going on’ (I described my symptoms very specifically but not name any diagnoses). She nevertheless gave me a prescription for Cipro antibiotic eye drops (i.e. totally not appropriate for viral or non-infectious conjunctivitis), and sent me out the door.”
Another: “My husband took our 2 year old son to an urgent care with a nursemaids elbow. Picture sent from preschool was textbook. I was working in the ER and it was very busy, so this was the best idea (I thought). They took a bunch of X-rays. NP told my husband that she thought it was a nursemaid’s too but it’d get reduced by the X-ray tech while positioning for X-rays. … Nearly $2000 worth of X-rays later (had crappy insurance) and our son gets discharged with the diagnosis of ‘a sprain’ and told to follow-up with ortho in a couple weeks if not better. I walked in the door after a 10 hour ER shift…and reduced his nursemaids elbow. 
. Same hospital system I worked in … so besides a terse conversation with the supervising physician at the UC about educational gaps…we paid our $2000 bill and let it go. “
Another: “My 15 year-old nephew injured right hand and went to UCC. X-ray showed fracture at the base of first metacarpal. PA placed orthoglass splint in 2 pieces, with the space at the area of fracture. Thankfully, my sister (a school nurse) asked me if this seemed correct, and I was able to get her in with outpatient ortho right away for appropriate splinting. Add to this that he is a pitcher and this was his dominant hand, could have had much more severe repercussions had the follow up been delayed for 1-2 weeks as directed.”
Three times wrong
Another: “Pt. 60 something female, former smoker (20+ years of 1-2 packs per day). Came in with complaint of cough. The urgent care I work at is her PCP (usually no clear ‘provider’ and care is disjointed) and no screening CT lung has ever been ordered (a screening CT is a low-dose scan once per year to look for cancer in high-risk patients like this one).
“First visit: clear CXR, prescribed antibiotics and steroid for ‘cough’ by PA.
“Second visit 3-4 weeks later: another round of steroids [prescribed] …
“Third visit several weeks later: now complaining of bloody sputum, CXR read as “clear” by PA at time of visit, they Rx a third round of steroids + antibiotics. Over read from radiologist comes back next day that there is … (swelling in the lymph nodes) highly suggestive of cancer, MD who gets the report orders CT chest.
“CT chest results come back when I’m on shift and yes, this lady has lung cancer. I’m reading through her chart because I have the lucky job of giving the news to a patient I’ve never met before. … This lady presented with a symptom with no identifiable cause and just got thrown meds at her three different times, despite being high risk for lung cancer.
“Sometimes we can’t always perfectly identify a cause of a symptom, or will start treatment before having the results of a diagnostic test based on clinical assessment. This is called ’empiric treatment.’ However, this patient’s risk factors walking in the door make that inappropriate and the fact that it happened THREE times in a row is shameful. …
“The next time I see the PA I bring this to his attention and he’s like, ‘yeah but she quit smoking 15 years ago,’ as justification for not doing more of a workup sooner.
“At which point my face melted off, because he thinks this means there is no reason to consider lung cancer in someone with a 30 year pack history.”
Direct primary care
One solution for easy access to care is direct primary care, which doesn’t take insurance, but instead charges patients a monthly membership fee that covers all their primary care.
That monthly membership might be $50 a month for a person under 21, and $150 a month for someone over 65, as at Gold Direct Care in Salem, Mass., or $39 a month for kids 18 and under, $79 a month for people age 70 and up, and $139 a month for a family, as at Neucare in Lawrence, Kan.
Direct primary care also often includes things like discounts on MRI’s or X-ray’s or blood tests, and often inexpensive prescriptions. It usually includes referrals to specialists, but specialist care is not covered by the monthly fee. Depending on the practice, though, it can easily include things like stitches and other procedures that let you avoid the emergency room.
Outside of the insurance system, doctors are less overwhelmed with patients so they can get you in much sooner than a typical practice and even spend more time with you at the appointment. Direct primary care is not available everywhere, though, and many people prefer to stay inside the insurance system.
Another stopgap: Sometimes your insurance plan can have a telemedicine option for after hours, weekends or holidays. Doctors told us that this is not ideal, and several doctors we talked with said people may choose free telemedicine after hours, instead of calling the doctor’s office for whoever’s on call.
“There are some horrible telehealth programs out there, even ones run by insurers,” Dr. Jill Stoller, a pediatrician, told us early in the pandemic. “You call and say you have a sore throat, and they call in antibiotics for you. Some really bad medicine happens that way. It’s often free to the patient — say, no co-pay with Aetna’s telehealth provider. So you get sucked into it. And then there’s a second visit where we need to fix what was messed up.
“Telehealth needs to be done in the patient’s medical home — I know the patient, have the chart, know the history, and can do appropriate follow-up.”
Strains on the system
The strains on the system are real. It’s no accident that Amazon recently decided to offer One Medical, its recently acquired membership medical service, for $9 a month to existing Amazon Prime members, or $99 a year — a $100 discount from OneMedical’s standard rate. “Scheduling even a basic check-up can require waiting weeks, and when you finally do get in for your appointment, it often feels rushed and impersonal,” Amazon said in its announcement.
With a membership, a virtual visit will be free. “The new One Medical membership covers unlimited access to 24/7 on-demand virtual care, including video chats with licensed providers within minutes and an easy in-app ‘Treat Me Now’ feature that lets you get fast care for common concerns such as cold and flu, skin issues, allergies, urinary tract infections, and more,” the announcement said.
In places where there is a bricks and mortar OneMedical office, an office visit will also be an option (with the price depending on the member’s health insurance); appointments can be scheduled virtually.
There’s also Sesame, a pay-per-visit medical marketplace.
Another sign of the times is the recent announcement of “Carepods,” by Forward Health. It is “an AI-powered box for primary care,” with just a box, not a person.
“The CarePod pitch is easy to understand,” Techcrunch wrote in its announcement. “Why spend hours in a doctor’s office to get your throat swabbed for strep throat? Walk into the CarePod, soon to be located in malls and office buildings, and answer some questions to determine the appropriate test. CarePod users can get their blood drawn, throat swabbed and blood pressure read — most of the frontline clinical work performed in primary care offices, all without a doctor or nurse. Custom AI powers the diagnosis, and behind the scenes, doctors write the appropriate prescription, which is available nearly immediately. The cost? It’s $99 a month.”
Is this a step forward from the current urgent care landscape? Would you trust an AI box more than a physician assistant? Maybe not.
So what do we do if we want to avoid urgent care? I asked Mitch Li, an emergency medicine doctor who is a founder of the “Take Medicine Back” Facebook group and associated nonprofit, which has as its mission returning the doctor-patient relationship to what it was before for-profit companies started using the healthcare system to make money first, what he describes as the “corporate practice of medicine.” His first answer was a global one.
“The ‘so what do we do’ answer is really a fundamental overhaul of our system that has ripped apart the physician-patient relationship by allowing for the unfettered corporate practice of medicine,” he wrote in reply. “That’s what we (Take Medicine Back) are working on. But we are talking about undoing a half century of policy, deregulation, and commoditization of the physician.”
What you can do
Again, it’s worth noting that most urgent care visits have good outcomes (or they wouldn’t still be in business). So urgent care may be the best option. What can you do?
Li wrote: “If you decide to visit an urgent care, call first to ask if there are physicians on site (M.D. or D.O.). Most likely you will not get a straight answer or will be told that you will see ‘a provider.’ This is a red flag.”
A retail clinic like a CVS Minute Clinic, for example, might have a nurse practitioner or a pharmacist on duty. CityMD, a big chain, also has plenty of nurse practitioners and physician assistants, despite the name.
Another doctor, this one an emergency medicine specialist, wrote: “The best solution I have seen, which is only an option in some areas, is a physician-owned urgent care that is staffed by board-certified physicians. I may be a bit biased, but [emergency medicine] would be preferable, then family medicine (for adults or children) or internal medicine (for adults). I have some friends and a couple of my mentors who have done this. I have personally gone to some of the large urgent care practices for occupational health issues, and when it has been a physician staffing the facility it has usually been a good experience.”
Another wrote: “Patients should seek care at UCs that are staffed by a physician. Call and ask before going. If you can’t call and ask because it is too emergent, then come to the ER. Ensure minimum a physician is present and aware of the care. Many of these stories a well-trained physician will pick up from triage note alone or a quick presentation from the PA/NP. They then are involved in the most important part of the care, medical decision making.”
Li also wrote: “If the patient is able to, then seek to establish a long-term trusting relationship with a direct primary care physician. These doctors are just as fed up with the system as you are, and have left corporate medicine to allow plentiful time with their patients.”
Direct primary care does not exist everywhere. A good place to search is this map from the DPC Alliance, which is doctor-owned. There are a number of clinics springing up calling themselves D.P.C. that are not strictly D.P.C., so it pays to do your homework.
