Every Wednesday I would do a primary care shift from 1pm-5pm downstairs in the Internal Medicine clinics before starting my urgent care shift. Each half day I would be scheduled with 10 patients and almost always run over. It was like swimming through mud. I never felt satisfied. Never felt like I accomplished anything for my patients other than pushing meds as a primary care doctor.
During my urgent care shift I would see 3x that number and be done faster and feel much less exhausted. There was alway a sense of accomplishment because I was able to address the chief complaint on the spot.
So wtf is wrong with primary care? A lot, but I’ll try to focus less on why traditional family medicine is such a waste of my time and more on why urgent care medicine is so awesome as a career.
Family Medicine Skills
Family medicine residents fear that they will lose their family medicine skills; it’s usually their main hesitation to choosing urgent care as a career even though the hours are better, as is the pay. They want to still be able to do inpatient medicine, do deliveries, and manage type 2 diabetes in their clinics.
If you really are the type that is worried about losing your inpatient and OB skills then you must go out in the middle of nowhere with high physician shortages. This ensures that you are held to local standards should something go wrong.
Anywhere else and you will be compared to other obstetricians who have immediate access to doing a C-section. Or you’ll be compared to an internist who solely practices as a hospitalist.
I’ve heard the reviews from residents of the inpatient family medicine attendings at the teaching hospitals, it’s usually not flattering.
Primary Care Skills
What most family residents refer to as ‘family medicine skills’ isn’t OB or inpatient medicine. They want to go into an outpatient primary care practice so that they don’t forget how to manage chronic diseases. This is misguided.
How do I say it nicely? No, I’m kidding, I don’t care to say this nicely. A pharmacist could manage 90% of the chronic diseases out there. The reason for that is that 90% of patients prefer to have their diseases managed with medications.
98.3% of all the lab tests we do are bullshit and only meant to manage the lawyers looking over our shoulders. Adjusting patient’s insulin medication based on A1C’s is ineffective but few patients are willing to regularly do their finger sticks.
Can you cure type 2 diabetes? Of course you can. People do it all the time. But that’s not what a primary care doctor is aiming to do. They want to introduce some shitty Januvia because they read that one study, that one time. And then strategically add metformin, followed by a sulfonylurea… but not too soon because there was that other study, that other time. And titrate off the metformin as soon as the GFR hits 51.
Urgent Care Medicine
Medicine in the US is a concierge service that is retail focused. We cater to those who are willing to make the biggest fuss. Customer service is much more important than the quality of medical care you dish out.
The statement that physicians who are nicer are sued less should drive this home pretty well. My patients still ask me about the surgeon’s bedside manner whom I refer them to. Not how good his surgical skills are but how caressed their gluteus will feel after going to them.
I don’t mind titrating someone’s ACE-I or ARB’s. I don’t mind telling my patient that the BB they are on is a little outdated for HTN control. As an urgent care doctor I can ask my patients about their morning BS and know how to adjust their insulin. Adjusting meds isn’t hard.
But … but… seriously, how many of your patients are even taking their night-time insulin? How many of them have a log of their blood sugars? Or even have batteries in the glucometer that they drop on your lap?
I don’t blame the patients as much as the medicine that’s practiced in the US. Empowering a patient makes you come across as less empathetic.
Urgent Care Skills
For every fragile primary care physician out there, there are quite a few hard-working urgent care doctors who do it all. They manage primary care issues, manage high acuities, coordinate care with social workers, report child abuse, and remove corneal foreign bodies.
The two family medicine doctors at Kaiser Permanente who had the best patient satisfaction scores were among the most incompetent physicians. I wouldn’t let them wipe the screen on my laptop. Their patients were on multiple opioids, multiple anxiolytics, and a plethora of HTN and cholesterol medications. But they were loved. They were LOVED by their patients.
These two weren’t bad human beings. It’s just that they evolved to satisfy patient’s desires to have empathetic physicians who will hold their hand as they eat themselves into insulin-dependent-diabetes.
Your urgent care skills will always include plenty of primary care skills. In fact, you’ll be able to see the craftsmanship of many different primary care doctors. You’ll learn from what they’ve done. You’ll learn that the quietest ones are often the best primary care doctors.
Urgent care medicine has a weird schedule – evenings and weekends. For the doctors who are looking for a lifestyle career, urgent care is terrible. Then again, medicine might be terrible for anyone who wants to have a lifestyle career.
The advantage to urgent care medicine as a career is that you have longer shifts and can therefore spend fewer days in the clinic.
The schedule is flexible enough that you can easily trade with colleagues, pick up shifts last minute, and call out sick without having to worry about rescheduling patients.
You can kill a patient just as much with the wrong prescribed medication as you can with surgical procedure. Primary care doctors unnecessarily fear the procedures they have to perform in the urgent care.
Remove an IUD. Insert a nasal packing. Remove a corneal FB. Repair a laceration. Do a biopsy. Repair a tongue laceration. Perform an maneuver. Perform an ulna block. Repair an auricular hematoma. Drain a PTA.
Whatever you don’t know, you will learn from colleagues. And if your colleagues are challenged, there is always Google.
As a family medicine doctor who has urgent care medicine experience, I can work damn near anywhere.
I’ve worked in the ED, cosmetic clinics, marijuana clinics, pediatric offices, and in occupational medicine. And by far my favorite, telemedicine.
I’m sitting at a cafe right now writing this post while I’m on a text-based telemedicine platform, earning my dollars.
I don’t have to live near a large hospital. I need a panel of primary care doctors who will refer specialty patients to me. I don’t need to be glued to an OR, nor do I need fancy anesthesia equipment to do my job.
Being able to see all ages of patients allow me to open up shop anywhere. I can open a community clinic or a walk-in urgent care. I can run a specialty clinic focusing on Diabetes or Renal disease. I can open a women’s center, a laser clinic, or a walk-in STD clinic. The possibilities are endless.
The income will be lower than what a neurologist or orthopedist will earn but at this stage in my life I care more about the diversity of opportunities. I didn’t have the brains, grades, or stamina to apply to those elite specialties anyways. Smart fucking bastards.
Switching to Urgent Care
I have written a lot about what it’s like to practice urgent care medicine and how to switch to urgent care from various other specialties. A search for ‘urgent care’ on this blog should take you to every one of those posts.
The acuity is higher, yes, but the majority of patients are super easy. Americans like convenient access and that’s what you see in an urgent care, someone who got tired of waiting for their primary care appointment.
Most cases are just primary care patients. Some will be urgent visits such as cellulitis, pain, abscesses, or lacerations. These are rare.
Most ‘abscesses’ are epidermal cysts and don’t need to be drained. Most lacerations don’t need to be repaired. This might be disappointing to most procedure junkies but as luck would have it, most patients prefer interventions so you’ll have plenty of customers.
If you are an ER doctor then you just need to be a lot more conservative – order fewer tests. Unlike in the ER where simple stuff often turns out to be sinister, in the urgent care most sinister presentations are totally benign.
For the family doctors, stop spending 4 hours with each patient. You’re not responsible for their primary care issues. Focus on addressing the main issue that the patient presented for. First, triage, next, refer, finally, manage.
It’s okay to refer a patient to their primary care doctor for benign and chronic issues. The other 30 patients who are desperately waiting to get in to be seen that day in the urgent care will appreciate you learning this skill.
Current pay rates for urgent care doctors is in the $140/hour range. You can get as much as $200 if you are going to work in remote locations or in the prison system.
Quite a few medical groups are paying their urgent care doctors up to $160/hour on salary. This is likely because the demand for urgent care or same-day care is going up.
Pay differentials for weekends, evenings, and cold and flu seasons are becoming popular as well. This allows an urgent care doctor to earn much more by working the same hours but more strategically. I used to pick up in the cold and flu season for the extra pay because the work was easy.
Working in remote towns with minimal access to healthcare can be a cash-cow. You can take call for the ER, cover OB in the nearby hospital, do some telemedicine, and of course staff the urgent care.
Some urgent care doctors have found $600k/year gigs by working their asses off somewhere in the middle of nowhere for a couple of years.
Medicine in Retirement
Practicing medicine in retirement could stretch your retirement budget. With a couple of hours of work you can have more than enough money coming in. But maybe you don’t want to be doing 10-hour shifts in a busy urgent care.
That’s why being a family medicine doctor with some urgent care experience can be beneficial. If you want to use your medical skills during retirement for some income, you can do a bit of telemedicine or pick up a few hours for a local clinic.
Practicing family medicine in retirement is tougher because you often have to commit to a few weeks/shifts to cover someone on maternity leave or a PCP who is out on sick leave.
As an urgent care doctor you can wait until last minute and pick up a couple of hours in a busy urgent care a few times a month. The more efficient you are, the more likely for them to bring you back.