A Tale of Two Sore Throats: On Retail Clinics and Urgent Care

A Tale of Two Sore Throats: On Retail Clinics and Urgent Care

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Leslie Kernisan new headshotSix years ago, just after arriving in Baltimore for a winter conference, I fell sick with fever and a bad sore throat.

After a night of feeling awful, I went looking for help. I found it at a Minute Clinic in a CVS near the hotel. I was seen right away by a friendly NP who did a rapid strep test, and prescribed me medication. I picked up my medication at the pharmacy there. The visit cost something like $85, and took maybe 30 minutes. They gave me forms to submit to my California insurance. And I was well enough to present my research as planned by day 3 of the conference.

Fast forward to this year. After feeling a bit blah on a Monday evening, I developed a sore throat, headache, and fever overnight.

I figured it was a winter viral pharyngitis, rearranged my schedule, and planned to make it an “easy day.” Usually a low-key day plus a good night’s sleep does the trick for me.

But not with this bug.

This one gave me chills, a splitting headache, body aches, a fever of 102, and a sense of serious misery. Plus that awful sore throat. A dose of ibuprofen 400mg would beat back the symptoms a bit, and allow me to eat and sleep. But after about four hours, I’d find myself shivering and feeling horrible again.

And the following day, Wednesday, I felt even worse. I started wondering if maybe I had the flu, or could it be strep throat, since I didn’t have a cough?

I thought about going to the doctor, but I felt so sick and I didn’t want to go through the hassle unless there was a decent chance of benefit.

Because in truth, even though I get my care from a large well-regarded health system that offers online appointment scheduling, a portal to review my outpatient lab results, telephone advice nurses, and other conveniences, I still don’t like going in because it’s a big place and the experience never feels…delightful, shall we say.

I looked through UpToDate online and tried to figure out the likelihood that a doctor’s visit would change management (most adult pharyngitis is viral) but my mind was too fuzzy and so I stayed home in bed.

However, that night my husband said he was starting to get a sore throat. I also spoke to a doctor friend on the phone. She thought my symptoms sounded an awful lot like strep, and urged me to go in and get a rapid strep test. I decided that if I didn’t feel a lot better by the next morning, I’d go in.

I was a little better the next morning (day #3 of my illness) but not a lot. The body aches were better, but I’d developed a killer earache, and it still hurt too much to eat unless I had recently taken ibuprofen. My temperature off ibuprofen remained 101-102.

So I called the phone appointment line, explained my symptoms, and was given an appointment to see my own assigned doctor. (No urgent care clinic available I was told; this health system encourages open access to your own doctors.)

As I had expected, it was a miserable hassle. The big facility’s big underground parking lot was full but they kept letting cars in, so I found myself along with twenty other cars on the bottom floor, with a staffer waving his arms and telling us to find a way to turn around.

My doctor’s waiting area was pleasantly uncrowded, and after I’d paid my $20 co-pay I was called by the medical assistant (MA) right away. This, I’ll admit, was nice. “How’re you doing?” she asked as we walked to the vitals station.

“Sick,” I replied. “That’s why I’m here. I haven’t felt this bad in years.”

The MA made a sympathetic noise, checked my vitals, and then put me in an exam room. She asked me to tell her about my symptoms, which I did.

And then she proceeded to quiz me about my lifestyle habits. Did I exercise regularly? Just what type of exercise do I do? How many times a week? And for how many minutes? What about drinking? How many times a week? How many drinks in an evening?

Now, I have always found it intrusive and annoying when clinic staff ask me these types of questions. I know why they do it and why it’s overall important, but as a patient I’ve always disliked it.

This time, having come for an acute care visit after feeling miserably sick for days, I was seriously annoyed. I have a low BMI, low blood pressure, and a beautiful lipid profile. (I credit genetics/epigenetics.) In other words, I am not in dire need of lifestyle interventions. But I gave the MA some brief answers and in truth I inflated my exercise levels a bit, because I didn’t want them to get on my case, or get distracted from my top priority, which was getting my illness evaluated.

A few minutes later, my doctor arrived. I had to repeat the story of my symptoms. She listened to my lungs and peered in my throat. And then she announced she would do a throat culture.

What? What about a rapid strep test, I wanted to know.

“This is a rapid test. It’s a rapid throat culture which gives us results in 6-8 hours. We don’t have any other strep tests.”

I looked at my watch. It was 11:40am. “Let’s get your culture in to the lab,” said my doctor. “If they start running it soon, we might have a result by evening. You can check online and if it comes back positive, call the advice nurse and they’ll have a doctor order your prescription, which you could pick up tonight.”

I sat there, sick, spaced out, and very disappointed that there wasn’t a rapid strep test available.

My doctor handed me a paper bag. “Take this to the lab on your way out.”

It took me a little while to process this last bit. Not only did they not have a rapid strep test, but they were now telling me to go deliver my sample to the lab. Helpfully, the doctor gave me a “After Visit Instructions” handout, on which she had checked “Specimen drop off: Please take a number and the next available receptionist will help you.”

I went to the lab. The waiting area was overflowing with people. I took a number (361) and then discovered they were now serving number 329; there were at least 30 people ahead of me. There was no bin or spot to drop off my specimen, so I sat huddled in a chair as my ibuprofen started wearing off and my fever returned.

It took them twenty-five minutes to call my number. I had to tell them my name and address, and give them my ID again. “No co-pay required today!” the receptionist announced brightly. I told her I’d been waiting quite a while just to drop off a specimen and why didn’t they have a bin? She apologized and said they used to have something like that, but then the space was rearranged and they took it away. I consoled myself thinking that since I’d dropped off my specimen at 12:25pm, hopefully I’d have a result by 8:30pm.

I went home to my bed and my ibuprofen. That evening I started checking the portal online. No result. No result. No result. I took more ibuprofen and spent another restless night with fever, sore throat, and earache.

The next morning, I checked again. Hallelujah! A positive strep culture! Which, I noticed, had been reported at 9:45pm after the specimen was “collected” at 1:57pm.

I called the advice nurse, she arranged for the phone doc to call in my prescription, and then I had to schlep back to the health center to get my penicillin. And finally that afternoon, I started to really feel better.

Should I go to a retail clinic next time?

I don’t like being sick but it’s always instructive to be on the patient side of things.

Because my PCP didn’t offer a rapid strep test, my treatment was delayed by almost 24 hours. I lost an additional day of work and some income. My beleaguered spouse took care of our two little kids on his own for an extra day. Plus it’s not fun to have fever and a splitting earache.

All of these problems are a big deal to me. But they are an externality for the big organization that manages my healthcare. Rapid-strep tests can be expensive for a provider; only 5-15% of adult pharyngitis is strep so unless you are selective about who gets tested, you end up with a lot of negative rapid tests that often get followed by a throat culture.

As for making your patients drop off their specimens at an over-crowded lab, well…it’s quite easy to see how that happens in a big organization. (Presumably it’s cheaper or easier than having staff do it.) I didn’t like it but I’m not going to leave the provider over that.

I will, on the other hand, probably go look for a retail clinic next time I’m acutely ill and think I might have a treatable infection. I haven’t yet decided just how much a day of health is worth to me, but it’s surely more than the cost of a retail clinic visit minus my $20 copay.

Now, you may be scoffing and thinking that since I’m a doctor of course I can afford a retail visit. But if you have low socio-economic status, a day not working can be an even bigger deal than it was for me. When I worked a salaried doctor job I had paid sick days, but that’s not true for many workers.

However, I would be worried if many older adults with chronic health problems started going to retail clinics. That’s mainly because I’m skeptical that retail clinics can provide the right care – whether acute or chronic – to people who are medically complex and getting care from other providers.

I also worry that retail clinics will over-prescribe antibiotics and other medications, in part because patients often want these things.

Of course, more conventional primary care urgent care clinics suffer from the same problems. Over-prescribing of antibiotics is common in outpatient care, and medically complex people often get sub-optimal care during acute and chronic visits. So perhaps it’s not fair to bash retail clinics excessively, until our primary care clinics get much better at what they do.

What constitutes good urgent care?

No matter what one’s age or medical history, one should be able to access a good urgent care experience when acutely ill. By good, I mean that:

  • The encounter involves a minimum amount of friction and burden. I put off my own doctor’s visit because I was reluctant to face the hassles while feeling sick. Imagine if I were employed and had cancelled an additional day of clinic, in part because I was sick and avoiding the hassle of my doctor’s office. My employer and patients would’ve been upset, and rightly so. 

  • Delays in diagnosis and treatment are minimized. Even when delays in treatment aren’t medically dangerous, they impose a serious burden on patients when the delays affect ability to work or care for others. 

  • Diagnosis and treatment are in accordance with recommended practices. It can be hard to agree on the finer points of what is recommended practice, but in general, care should be similar to what is recommended in UpToDate, for instance. Avoiding over-prescribing of antibiotics is an issue in all urgent care settings. 

Should patients be quizzed about healthy lifestyle habits during an urgent care visit? This would be an interesting topic to debate, as it requires weighing population health benefits with patient satisfaction.

Will I go back to my PCP next time I need urgent care? Maybe, but if I think it’s strep again, I’ll probably look for a reliable urgent care provider who offers rapid strep tests. For working adults who aren’t medically complex, convenience and minimum delays in treatment are key.

 

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50 Comments on "A Tale of Two Sore Throats: On Retail Clinics and Urgent Care"


Member
Dec 2, 2016

I have to say that not all PCP offices operate like that for sick visits. And if they do, they’re probably pretty lousy, frankly.
I’ve been in primary care for 16 years and at every place I’ve worked, we’ve always differentiated between acute visits and routine follow up. Part of the issue with all the lifestyle questions is templates for EHR, as well as meaningful use requirements (which make the EHR both meaningless and useless).
Retail clinics aren’t terrible, nor are they the best solution, but the truth about your tale is this: your PCP’s office kind of sucks.
Even if you’d been there for routine visits, asking a patient to schlep their own specimen to a lab is just, well, cheap (they don’t want to pay someone to have to do it). It’s also kind of gross. And not having a rapid strep screen is also cheap (they don’t want to either do the test themselves or have the staff do it).
I know I’m about a year late to this conversation and stumbled on this while trying to find average cost of strep testing for folks, but it once again reminds me just how incredibly lucky I am to work in a direct primary care office at best and a small clinic that isn’t too big to be personal for patients to get care that is both appropriate but personal.
If your first inclination is to not go see your doctor when you’re ill because you hate the process, then your doctor’s office is doing it wrong.

Member
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Member
Rachel
Oct 3, 2015

This case of strep throat sounds like a nightmare! I always dread going to the doctor when I’m sick because of all the hassle. Sometimes it is easier to go to an urgent care clinic, however, I feel even the urgent care clinics are becoming increasingly busy and crowded. I can’t even get in to see my doctor when I’m sick, so I am then routed to go to an urgent clinic for my needs. I am becoming more familiar with urgent care clinics, rather than my own PCP’s office….

Guest
Gladys Vazquez MD
Mar 30, 2015

What you didn’t mention in the article
1.Did you have strep throat diagnosed at your visit to the urgent care?
2. If you didn’t, why did you get a prescription?Did they do a follow up throat culture?
I admit the care at your PCP was substandard compared to what we make available to our patients. What we do find from our patients that visit urgent care centers are; unnecessary and inappropriate antibiotic prescriptions as well as unnecessary and inappropriate xrays, tests etc
Urgent care centers and Minute clinics are like McDonalds or any fast food chain, fast and immediately satisfying but ultimately bad for your health.

Guest
Tara Oakman
Feb 6, 2015

This was a great piece! Thanks so much for sharing. Reminds me of the latest Call for Proposals put out by the Robert Wood Johnson Foundation to better understand consumer perceptions of value, especially in different delivery settings, such as retail clinics, primary care, etc. http://www.rwjf.org/en/grants/funding-opportunities/2015/optimizing-value–consumer-focused-value-trends.html

Guest
MD as HELL
Feb 4, 2015

You never said if your strep screen at the MinuteClinic was positive. Never said what medicine you were given. Even strep is feeling better by day three.

Did you need to go either time, doctor?

Guest
Gladys Vazquez MD
Mar 30, 2015

I couldn’t have said it better. Thumbs up.

Guest
Anesthesia doc
Mar 5, 2015

The rationale for treating strep throat is to protect the patient from kidney and cardiac damage that can result from strep infection, not to hasten the resolution of the initial symptoms. So, yes, both of her visits were necessary.

I feel that the unsatisfactory experience at her primary care “provider” office is due to the encroachment of the government upon the provision of medical care–oops I mean “healthcare.” The intrusive, annoying and tangential questions to which she was subjected by the MA are merely to feed the EHR/government data mining of citizens’ lives (apparently unhindered by HIPAA) that is a major part of Obamacare. I agree that it is off-putting to be asked this litany of questions by the MA, but it would be even more inappropriate for her physician to waste time ticking off these boxes in the obamaEHR rather than addressing her chief complaint. This is the concept of “team-based” (AKA needlessly fragmented and repetitious) care that our lawyer-president has decided is an improvement to traditional medical care. Go figure. The “retail clinic” is apparently not saddled with the same inane requirements to robotically probe into the non-pertinent details of the patient’s personal life (data mining again). I hope the same applies to urgent care facilities, which are traditionally staffed by a physician, with or without NPs/PAs.

Please pardon my rant…

Guest
Eve Harris
Feb 1, 2015

glad you’re on the mend, Leslie. Yes, all the options are flawed, even for sick doctors with insurance and relationships with their PCPs.
Re: urgent-care-in-a-box: one client sticks in my head. His series of visits to the convenient clinic for back pain postponed his dx of serious disease. Visit after visit they collected his Medcare $ but to the best of my knowledge never referred him out to a more appropriate provider. So much extra suffering!

Guest

That is a sad story but I’ve seen the same thing happen with patients who go see their PCP or another more conventional doc over and over again. It’s important to be able to catch red flags, and take things to the next level.

Guest
Liliana Rojas
Feb 1, 2015

It is obvious that the heath care system we practice has a lot to work on. The fact that we have to go through questionnaires in order to see the doctor is insane. Why? Well the doctor goes through it again. They are just wasting time.
The fact that you still had to take a number and wait is just annoying. We can’t put a timer to our sickness. Reminds me so much of a visit to the ER I had recently. I waited for over an hour before I could be seen by a nurse to take my vitals and then half hour before I was seen a doctor. So much for an emergency. I’ve looked at others countries health care system and their waiting time is nothing compared to our facilities here in the U.S. Thankfully everything worked out for you and you didn’t become more ill over the wait of the results.

Guest

The techies keep promising us that point-of-care diagnostics and more efficient care are right around the corner…I can certainly envision better systems but hard to know when most of us will be accessing them.

Guest
Trudi
Feb 1, 2015

Nice… while you and the other patients were waiting to deliver your specimens… you were also trading germs. You are lucky you didn’t bring some other malady home with you.

Guest

I have little kids so I am constantly being exposed to various maladies…but agree it seems nutty to cram sick people together in the lab waiting area.

Guest

Great perspective/write-up, Leslie! As you know, I’ve become a believer in de novo delivery models such as Iora, ChenMed, CareMore, etc. as it’s so difficult to re-engineer an existing practice. After visiting these sorts of clinics, it’s such a stark contrast with what the norm is, I always left saying “I wish my parents lived where one of those Medicare Advantage practices existed.” Obviously not all MA practices are great but I come away very optimistic when I observe these. Well, guess what, one of those came to where my parents live (thanks to Humana partnering with them) and I have experience as the adult child of elderly parents.

At my folks age, most don’t want to change what they are doing. It wasn’t that they were getting bad care, but I knew as the seas get rougher, I wanted a seasoned geriatrician/PCP who wasn’t driven to be a referral machine. It wasn’t easy but eventually I “won” and my folks made the switch. They are now in a no-premium MA program and are shocked (in a good way) at the care/attention they are getting. They can reach someone 7×24 and can get in same-day, if necessary. My siblings and I all have their care team’s emails and even the doctor’s cell phone. Like the vast majority of people, we greatly respect the doctor and won’t abuse it but it’s sure nice to know it’s there.

While far from ubiquitous, these sorts of models (along with others like Qliance, Paladina Health, etc.) are growing rapidly serving commercial clients, Medicaid and Medicare. I haven’t met more professionally satisfied doctors (and other care team members) and the patient satisfaction rates are off-the-charts. The more doctors and patients see and demand there is a better way, the more we’ll realize the full potential of the immense talent and compassion present in the healthcare professionals that I’ve seen. It’s particularly interesting when these de novo models team up with established players to establish de novo practices essentially across the street — it’s a great way to accelerate those established players’ transition as it overcomes the myths their staff may believe.

Guest

Dave, I haven’t yet seen one of these newer practices up close and in action, but agree that it’s promising. Nice that your parents got into one.

If patients have choices and feel able and empowered to switch to better providers, that will be a good thing.

I do think it can be hard for many people to judge some aspects of healthcare quality; customer service is easy to assess whereas whether or not referrals are appropriate is trickier.

Guest
Trisha Allamon
Jan 30, 2015

I’m a struggling PCP in a healthcare system and I totally understand. I no longer have my nurse ask my sick patients a lot of questions because 1. You are sick, 2. Nobody likes it, and 3. Neither of us have time for that! Also, I am honored to care for a loving, yet elite patient population. Of course we have rapid strep tests, and if I found it negative but necessary to do a culture, it is customary to START the antibiotic. My patients and my city demand that I see each of them as a human and not a number. I wouldn’t be able to get away with that, and really what MD should?

Guest

Wish I could’ve seen you! Sounds like you are in a smaller practice setting where you get to have more of a say in things.

It is sad that as doctors we find ourselves turning towards “elite” practices in order to feel decent about doing our work.

Guest
Jan 30, 2015

Re access to records:

“And then she proceeded to quiz me about my lifestyle habits. Did I exercise regularly? Just what type of exercise do I do? How many times a week? And for how many minutes? What about drinking? How many times a week? How many drinks in an evening?”…..and likely medically relevant questions about other…more sensitive….lifestyle habits.

I’d be glad to have all this in my personal health record if it were on a thumb drive that I controlled….or a highly secure cloud storage system that I could release when I felt it was appropriate…but until that system is developed I am a big critic.

So far no one I know has ever seen me as a paranoid character type…but all this EHR stuff makes me think I want to sign up for being a suspicious/paranoid character type!

Guest
Bill Springer
Jan 30, 2015

Seems like in this particular instance, the retail clinic substantially outperformed the primary care clinic. Perhaps we’ll see a middle ground emerge, with retail clinics tied via electronic medical records to primary care clinics so that the attending provider can access the patient history without the delays and overhead of the primary care site unless needed due to the diagnosis or symptoms.

Guest

Agree that it will be really important that retail clinics, freestanding urgent care centers, and others make all clinical data easily available to patients and other providers.

I took my mom on a Sunday to a new urgent care clinic for a foot injury. They were fast, convenient, and capable. But they didn’t provide access to records; just a CD of her xray which she promptly misplaced.

Guest
Steve O'
Jan 30, 2015

Make all non-controlled substances off-prescription without renewals allowed. That way, a good dose of penicillin’s just a walk-in to the pharmacy.

Member
Dec 2, 2016

Steve, perhaps you could read up about antibiotic resistance and super bugs and our over use of antibiotics? Then you might understand why penicillin should not be available over the counter.

Guest
Jan 29, 2015

Whenever I wonder if I’m seriously out of sync with what my expectations are when dealing with the medical-industrial complex, I’ll refer back to this post for a reality check.

Truth is, we are *all* out of sync, since the medical care delivery system is out of sync with itself, so how on earth would patients be able to mesh with it? Everything gets ground to mincemeat in its out-of-alignment processes, and then there’s the hand-wringing about infections spread within the system. By, say, some poor soul huddled in a chair, holding a number, who’s carrying around streptococcus aureus when she’d really rather not.

Anyone wonder why this comedy writer and erstwhile journo continues to write snarky posts about marriage counseling for the doctor/patient relationship, or comic screeds about patients getting access to their own records?

Leslie, I love you. Fo’ realz. I hope you’re feeling better by now …

Guest

Thanks Casey! yes much better…like most people my age, I have no substantial ongoing health problems.

This incident certainly left me wondering how awful things must be for the people who are seriously ill or have chronic conditions…

Guest
Ducklady
Feb 4, 2015

I can tell you, as someone married to a person with a serious cardiac problem: We’re terrified. We know no one really cares about us, even the people who want to care but are either in survival mode themselves or not allowed to do anything but follow “protocol.”

We know we don’t matter, that we are cash cows to be milked until it no longer makes profit for the corporation and then discarded. Hence, we are terrified and avoid contact with the medical system whenever possible.