In my last post, I discussed the idea of a medical home and the comprehensive healthcare it is meant to provide. For families for whom insurance, work scheduling or other demands make seeing a doctor during regular office hours difficult, many turn to retail based clinics or emergency rooms to fill-in and provide care. Whether this is in addition to or instead of a primary care provider, it is a reality that many families are using clinics and emergency rooms to fulfill at least some of their healthcare needs.
The difficulty with receiving care in these settings, as opposed to a true medical home, is that the health care providers in these settings do not have a complete medical history or record. Each time there is a problem, a different health care provider is likely to provide care and therefore, the continuity of care is lost. Moreover, if there is a bigger problem or a bigger picture issue for the patient or family, the health care provider is really not able to help make the diagnosis and assist in formulating a care plan. Recently, I have come across a number of interesting articles,which examine some of the other pitfalls of using retail clinics or emergency rooms for care, particularly for children. Their observations and opinions are well worth sharing.
In a recent blog article on kevinmd.com, Dr. Roy Benaroch discusses a variety of reasons why – for good pediatric care – you should avoid retail clinics . He highlights the potential conflicts of interest that exist when a clinic is within a store that also sells prescriptions. He defines good pediatric care as:
Care that looks at the whole child, the whole history, and the whole story. To do a good job I have to review the history, the growth charts, the prior blood pressures, the immunization records, and more. Good care means I’m available for every concern—not just the sore throat, but the “Oh, by the way…” worries that are often more significant than the current illness. Things like “He’s not doing so well in school,” or “I think he looks clumsy when he runs,” or “What am I going to do about these headaches every day?” Every encounter is a catch-up on problems and concerns from before, to be reviewed and updated. Children are growing and developing, and every encounter is a snapshot of their over all well-being that can only make sense if it can be placed into a continuous album. At the retail-based clinic, the encounters are just a quick toss-off: an opportunity for genuinely improving health that’s thrown away.
He also points out the need for providers to be specialized in pediatrics and to be up-to-date on current medical recommendations. Providers in these clinics may be generalists and not up-to-date in the specifics of care for children.
A recent article in the New York Times highlights one potential hazard for children visiting emergency rooms for care – the increased use of CT scans. The article reports that the use of CT scans for children visiting emergency rooms has increased fivefold between 1995 and 2008, such that almost six percent of children visiting the emergency room for care are now receiving the scans. There are benefits and detriments to this increase:
…advances in the technology had resulted in improved image quality that can greatly aid diagnosis of childhood ailments. But the scans expose patients to high levels of ionizing radiation that can cause cancer in later years, and radiation is even more harmful for children than for adults.
The New York Times article goes on to explain that risks are low and the patients who need the scans should receive them. However, it raises an important question in my mind.
The article states that the scans are most often given for “children arriving with head injuries, headaches or abdominal pain.” Certainly, there are plenty of times when a child may visit an emergency room for a true emergency and a CT scan, if warranted, should be done without delay. But, I wonder whether there are also situations in which a child may be visiting an emergency room because of a headache or abdominal pain, which has been persistent and would likely receive a different approach to treatment if first presenting in the child’s medical home rather than an emergency room. In that setting, would a doctor, with the child’s complete history and without other emergencies pressing, chose alternative diagnostic options before ordering a CT scan. The CT scan might still be warranted, but perhaps not as frequently. I am not a medical professional and would not question the judgment of a medical professional, but generally speaking, the value of consistency of care with a primary provider seems prudent whenever it is an available option.
From a personal perspective, I understand that even parents who are the most attuned to the desire for continuous care may waiver when faced with a child in pain during off-hours. Parents who are unable to get their child to the doctor during work hours or whose child suddenly has pain at 9 pm (or 3 am) are faced with an unfortunate decision. While I certainly would take my child to an emergency room for a true emergency, I have chosen many times to wait for our doctor’s office to open in the morning rather than take them to a 24 hour clinic for a non-emergency case of extreme ear pain or similar problem. It is horrible to wait those hours with a child in discomfort; however, I know that in the morning a doctor who has the complete history of the problem will then address the problem. Just this week, I was grateful – again- that we are lucky enough to have a primary care pediatrician, who knows our child, is comprehensive enough to care for our children, and by seeing “the big picture” can coordinate care immediately with specialists whenever that is warranted.
To me, a physician I can trust, coupled with great practice management, is essential to a pediatric practice where I can feel comfortable taking my kids. What are some of the things you most value? What about adult primary care providers – are you using clinics and emergency rooms for your primary care or do you have and prefer the continuity of care provided by your personal primary care physician?