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ED To Urgent Care – A Career Change

Emergency Medicine Doctors Making The Switch To Urgent Care Medicine

Recently, we’ve had a few ED doctors who have requested to switch over to the Urgent Care. Emergency Medicine doctors have hard jobs, long hours, overnight shifts, and high acuity patients – switching over to the Urgent Care can be a great way to make earning an income in medicine easier.

In this post I want to give an overview of Urgent Care medicine and how Emergency Medicine docs can make the transition easier. With Urgent Care medicine expanding, Pediatricians and even Internal Medicine doctors will likely have a place carved out for them.

 

Medical Group Loopholes

Let’s jump right into the juicy stuff. Because some larger medical groups have chosen to keep the pay distribution transparent and “fair”, all ED docs and all FP’s get paid the same depending on their seniority and specialty.

This also means that an ED doctor could work in admin and they would get their ED hourly rate or they could see patients in the UC without having to settle for the lower UC pay rate.

 

How Much Do UC Doc’s Make

Before an ED doc starts worrying about how much less they might earn switch down to Urgent Care medicine, let’s review why UC medicine is so much easier than Emergency Medicine – I’ll highlight that below in the next few paragraphs.

Briefly, I have made somewhere around $85-150/hour working as an Urgent Care doctor, or Urgentologist, as they call them. It’s rare to find Urgent Cares which are paying less than $100/hour, if they do, it’s often because the workload is absurdly low.

 

ED Working Conditions

In the ED, you have a lot of people staring over your shoulders. Some ED’s are the main way for hospitals to make money. Others, are supposed to minimize admissions. Some are used by the indigent which means that it’s tougher to arrange follow-up and the chance of missing major conditions is higher.

In the ED, you have to deal with emergency level staff. They are a little more on edge, a little more strong-willed and a little rougher around the edges. The stress, tension, and hierarchy is palpable as soon as you step foot in any Emergency Room.

There are mandatory overnight shifts and having to cover holidays. The schedulers don’t give you much leeway, you’re scheduled for whatever you’re scheduled and room for negotiations is slim, quite unlike most UC’s.

As an ED doctor you are on the phone or doing curbside consults, a lot. You are paging specialists, talking to social workers, talking to EMS and family members. Seeing the patient is the easy part, dealing with all the peripherals is a whole another job by itself.

 

UC Working Conditions

I have worked in over 10 different urgent cares and a few ED’s over the years. I have worked in private solo practices, large medical groups, hospital based ones and concierge urgent cares. They all have the same thing in common which even my colleagues don’t recognize – it’s essentially fast paced Primary Care medicine.

The staff are often Family Medicine trained staff, usually a lot calmer, nicer and more patient. They aren’t in the rushing around mode, there is a lot less stress when dealing with them.

If anything, it’s doctors like myself who tend to think they are ED doctors, running around way too much and way too fast and stressing out the staff. They just tell me to unspaz a few times and I usually calm down.

I don’t have to deal with many specialists or social workers. Referrals can be made by the PCP’s in the follow-up appointments. I don’t have to deal with stressed out family members and I am not a drop-off location for family members to abandon their elderly ones with unmanageable dementia.

I have a few limited equipment available to me for procedures. My suture kit and abscess tools are made in Pakistan, which means that my scissors will cut 50% of the time and my Kelley’s are reliable enough to pry open very small abscesses.

Large, complicated sutures, children who need to be sedated, massive abscesses or complicated foreign bodies in the eye are shipped off to the ED. I work shifts on occasion when one of our AC’s or Docs disappears in a room for 1:45 hours to complete a lac – dude, if you are gonna deal with a 2-hour laceration then you might as well close the urgent care doors because you just made 8-10 patients wait.

UC Acuity

I don’t handle emergencies – despite what my urgent care colleagues believe, we are in the convenient care business, sometimes dealing with urgencies but never, ever emergencies. Let me explain this.

My colleagues believe that some Urgent Care sites are harder than others due to “acuity”. They share stories about some night when they had chest pains, abdominal pains, shortness of breath and weakness in elderly as their cases. Bless their hearts, and I am not trying to be mean, but I disagree with their assessment.

Some are even distraught because they have seen septic patients, patients with STEMI’s, PE’s and lethargic infants.

The point I am trying to make is that when patients come into the urgent care with obvious signs of emergencies or pending emergencies then they are no longer urgent care patients, they will be referred up to a higher level of care. I am not mocking my colleagues, not at all. However, the acuity they observe is not the acuity they manage – they, too, transport these patients to the ED.

When I ask them what they did with those higher acuity patients, often times they shipped them right out, either by EMS or POV. In fact, this should make for a very easy patient on the roster of patients in a work-day.

 

ED Vs. FP In The UC

When Family Medicine doctors switch over to the Urgent Care, they often feel a bit overwhelmed with the pace. However, they do quite well with the acuity since they are familiar with it. ED doctors tend to start out being overly aggressive or find themselves bored.

ED Docs & Simple Complaints

ED docs tend to score a little lower on the patient satisfaction scores and I want to highlight briefly why this is important. Urgent Care is offered by most medical groups as a patient satisfier – it’s convenient care, easy access for patients.

Any medical group which I’ve worked for has viewed Urgent Care as a questionable department. Most try to get rid of it and many in leadership find it unnecessary. And believe me, I have no desire for Urgent Care medicine to thrive or to completely disappear, but the fact remains that it’s not only growing in popularity but it’s quickly becoming a way for larger groups to either cut costs by diverting patients away from the ED or by increasing revenues through proper coding and Medicare refresh mechanisms.

A patient doesn’t feel dismissed in the ED when they are told by an ED doctor that their rash in the groin is nothing more than tinea or that their shortness of breath is simply a flare up of asthma or bronchitis.

However, do the same in the Urgent Care and it eventually turns into complaints and patients bouncing back because they didn’t feel that they were fully explained the etiology, process, and endpoint of their condition.

Studies show that patients want their doctors to be honest… in an optimistic fashion (?) and they want to be explained things. Patients want to feel heard by way of the doctor repeating things back to them and they like the doctor to demonstrate empathy. Other studies have shown that doctors don’t demonstrate empathy the same way the layperson does by making sad faces and ooh-ing and ahh-ing, even though the relevant part in their cortex lights on fMRI’s showing that they are in fact empathetic.

I realize that ED docs see a TON of worried-well’s and complaints which are benign. However, the ED doctor who can be a better salesperson and ‘sell’ the diagnosis or assessment to the patient will often do far better.

ED Docs & Higher Acuity Patients

It’s insane how well they do with super high acuity patients. They will not only recognize it immediately, but they also will administer the most beneficial initial intervention, compared to their more laid back UC colleagues.

They are also more likely to refer, utilize imaging and blood work. It’s common for a seasoned UC physician to not order any lab work or imaging for acute abdominal pain and even chest pain (with low pre-test probabilities, of course). And though this might sound shocking to an ED doctor working in a busy Emergency Room, it’s the most cost-effective and sustainable way to practice same-day medicine outpatient.

FP’s In The UC

It’s rare to see an FP doc transitioning comfortably into the role of a UC doctor. However, in time, they can become quite efficient and comfortable with the slightly higher acuity and the higher volume and pace.

They do a really good job with explaining things to patients and therefore they get much higher patient satisfaction scores. This is important to the medical group because the first interaction with the medical system for these patients is often the Urgent Care.

Because FP’s are used to having a ton of shit dumped on them, they adapt very quickly to meeting refresh goals or clicking on whatever the hell the administration wants them to click on for their metrics.

FP’s and a handful of the Affiliate Clinicians are often the most likely to complain about changes. However, change is a very integral part of an Urgent Care department as I’ll get into now.

 

Constantly Changing Urgent Care Department

The Urgent Care is a common place for leadership to implement change. The reason they do this is because it’s among the very few outpatient/low acuity departments which don’t get referrals coming in and don’t schedule appointments far in advance. Which means that changes in the flow or schedules won’t adversely affect patients.

Rolling out a new workflow? Start implementing it in the Urgent Care, the high volumes will provide a solid N-data that can be properly evaluated.

Trying to bring in AC’s? Put them in the Urgent Care, if they can make it there, they should do fine in other simple outpatient settings.

The EMR is about to get major security changes? Guess where it will get rolled out first… yes, the UC.

It comes with the job and if you don’t take it personally it’s really not that bad. The management often will give you plenty of heads up and they will do everything possible to make it seamless.

 

What’s Awesome About Urgent Care Medicine

What’s awesome is that the majority of my patients aren’t sick. They also aren’t there trying to look for a cure for their chronic back pain. Patients often have an acute issue that they need addressed, and if I am successful in addressing it, I am their hero.

They are pressed for time and want to get in and out quickly. If I can get in the room as soon as the nurse puts the patients in – damn near walking in before the door even closes behind the nurse – I am automatically an awesome doctor who is brilliant.

Patients do an amazing job of self-selecting based on their acuity and based on wait times. It’s rare to have STEMI’s or PE’s come into the Urgent Care – I guess patients somehow intuitively know when something is really wrong and they refer to the ED for that stuff.

When it’s cold and flu season, often times all you will see is … cold and flu. Because of insane wait times the rest of the patients just avoid the Urgent Care and wait for their PCP instead or go to the ED for their more urgent issues (sorry guys & gals of the ED).

When it comes to working for larger medical groups, specifically HMO’s, you can go at any pace you like. You can order as many tests as you like and refer and consult as much as you want and nobody will really come down hard on you. You can transfer every chest pain patient to the ED and you will still have a job to come back to the next day. You can order CTA’s all day long as long as your documentation can justify it. Order antibiotics all you want as long as you don’t associate the medicine with URI or Bronchitis.

I am not saying that you should be an inferior clinician, but let’s face it, a time comes when you are just tired of being on 150% of the time and you want to just relax a little. The larger medical groups have such a wide lens from which they view healthcare, and have such a low priority for their Urgent Cares that you won’t come under the microscope.

 

How To Be A Horrible/Amazing UC Doctor

Patient satisfaction scores – very important. If you can keep this consistently high then you are good to go. And no, it’s not about how many antibiotics or pain meds you give. Even those who refuse to prescribe that shit unnecessarily can have impressively high scores.

If you want the staff to like you then don’t order too many tests or procedures for the staff to do – that one is obvious. But even more important in the Urgent Care where it’s common for the nurse to not find a vein.

Don’t make patients angry. It’s so easy to piss off a patient in the Urgent Care that it can really make your life hell if you consistently make them angry. The thing is, patients can go to Primary Care or to the ED, but they choose the UC for whatever reason – because they made this choice, they don’t want it to be a shitty experience. Don’t get on the radar of leadership for being an instigator.

Move meat. ED doctors think they are fast but having worked in a few ED’s and many UC’s, they actually are a little slower than seasoned UC doctors. They can get bogged down with higher acuity patients and turn a simple patient into a complicated one.

Stay in the middle of the pack. If you are super fast then you will get dumped on a lot. If you are super slow then you might build that reputation. And though the latter isn’t a big deal, you will be considered far more valuable if you can slide by under the radar.

 

2 replies on “ED To Urgent Care – A Career Change”

Great advice and I really like your recommendations. As an older doc who has retired from ER and has been doing UC the last few years, I really can appreciate your observations. I’m financially independent but not psychologically ready to retire and UC has been a fun transition for me. It pays very well too in my opinion.

Thanks for sharing that and I appreciate your feedback, as always. I find that UC is getting more and more profitable but that also means that it’s getting more scrutinized. I think the shift to virtual medicine will happen with Urgent Care. Weird to say it, but we are all still early adopters of telemedicine technology as it’s being practiced today.
For the ER doctor who is already destroyed after a single shift but who wants a little extra income, I think they would do well to spend their energy doing some light F2F UC or even better, telemedicine.

I have shared in a few other posts that my gross income is a little over $200/hr now with telemedicine gigs. That may not be a lot but with the patients being infinitely easier, not having to finger any holes, not having to commute to work, and not having to order/interpret any tests, it’s a solid income.

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