When should I go to Urgent Care?

It’s 5 pm on a Thursday when your 5 year old is crying and saying her ear hurts, and she has a temperature of 100.0.  Do you:

a) go to Urgent Care now and get this ear infection taken care of so that she can go to school in the morning?

b) call your pediatrician’s exchange?

c) give her Tylenol and call your pediatrician in the morning?

Almost every mom I know would go to urgent care.  So the co-pay is a bit more, but it’s better than UrgentCareletting her wake up with pain in the night and then missing school and work in the morning to go to the pediatrician’s office.   But what happens when she has an allergic reaction to her antibiotic?  Or if her fever continues to rise?  Do you:

a) go back to urgent care?

b) go to the emergency room?

c) call your pediatrician?

Every day I hear parents say things like, “We don’t have a pediatrician, we just use urgent care.  We had a pediatrician when our kids were little and needed shots, but we haven’t been back there in years.”

The convenience of 24-7 healthcare is starting to take over the idea of a “medical home,” a primary care physician that knows you and cares about you and has an invested personal relationship with you.

The cost of this convenience is high, literally and figuratively.

Every night in the ER I see kids who have been ill for several days and made multiple trips to urgent care before finally landing in my ER.  Often, they just paid an urgent care co-pay, only to be told by urgent care that they needed to go to the ER, and then got stuck with an ER co-pay of up to $500.  One child had been seen twice at urgent care by two different nurse practitioners, was mis-diagnosed as having “a virus” twice, only to land in my ER after running a fever of 104 for five days.  I diagnosed her with a urinary tract infection that had spread to her blood stream, a very serious and potentially fatal illness.  Her family never called their pediatrician, who could have caught and treated her infection before it became serious.   No pediatrician would have let her run such a high fever for so long without ordering further tests and following up on her condition.

Then there was a twelve-year- old I saw with an undescended testicle—a testicle that never came down to its correct position in the scrotum during infancy.   He had yearly school physicals at a convenient care clinic, and got his vaccines through a school program.  He hadn’t been to his pediatrician since he was an infant.  His mom said that the pediatrician had mentioned his “testicle problem” when he was an infant, but that she thought it would clear up on its own.  They never followed up, and the convenient care school physicals did not include a testicular exam.  Tragically, this condition results in a non-functional testicle when not treated early.

I see depression and suicide attempts, drug abuse, head injuries, and STDs—all things that primary care pediatricians screen for, try to prevent, and treat in the early stages before kids land in the ER.  I ask these parents who their primary care doctor is so that I can call him or her, and it’s the same story, “Oh she hasn’t seen her pediatrician for years, we just use urgent care.”  Often, these kids miss teen vaccines, like the meningitis vaccine and the HPV vaccine.

So what should you do when you r daughter has ear pain and a fever at 5 pm on a Thursday night?  Call your pediatrician’s exchange.  If you disagree with the recommendation of the nurses’ answer line, ask to speak with your pediatrician.  Be honest.  Tell your pediatrician that you would like to go to urgent care tonight rather than wait to be seen in the am.  Guess what—most pediatricians are working parents too, and they understand your family time crunch.  They may even send you to a specific urgent care that will fax your child’s record to them. Or, they might tell you that your child’s condition is so serious that you need to go to the ER, and you will save yourself two co-pays.  They might even call in a prescription for your child right then and there.  And if your child doesn’t get better, your pediatrician will still be there for you, with a chart that documents all you child’s care.   If your child becomes very sick, your pediatrician can pull together medical records from multiple locations and coordinate referrals to specialists.

When do you use urgent care?  Is it ever appropriate?  How do you choose when to call your pediatrician and when to just go to urgent care?  I’d love to hear your honest answers.

Kathleen Berchelmann, M.D. About Kathleen Berchelmann, M.D.

Kathleen M. Berchelmann, M.D., is a pediatrician at St. Louis Children's Hospital and Washington University School of Medicine, director of the St. Louis Children's Hospital Social Media Team, and co-founder of the ChildrensMD hospital physician blog. Her work has been featured in print and online publications including the St. Louis Post-Dispatch, the Chicago Tribune, and TIME magazine. She is a frequent contributor to Fox2 News STL Moms. Kathleen and her husband are raising five children.

Follow Dr. Kathleen Berchelmann on Facebook: ChildrensMomDocs Twitter: @MomDocKathleen and connect with her on .

Comments

  1. Kathleen,
    Very good article.Hope all of our patients read these articles.Personally I do not want to diagnose and prescribe any antibiotics over the phone without examining the children, mainly because of safety issues.Please let me know your thoughts.
    Venkata

  2. Parents need to be educated on the importance of regular PMD visits (immunizations, management of chronic conditions, etc;). Many times unfortunately, it falls upon the ED and urgent care centers to manage these kiddos which is unfair for these healthcare practitioners and children, not to mention extremely dangerous if a child has a chronic condition (especially related to heart, lung, kidneys, or any metabolic condition). Patients often think incorrectly that everything related to a persons health history is available online.

  3. Dr. Newman says:

    I’m not sure if the tone of your blog is critical, cautionary or possibly a mix of the two. It does seem that you disparage UC centers based on anecdotal evidence. I am a rural physician with no local UC but my own primary care practice is rife with examples of things ED docs did very well and blatantly obvious mistakes and misdiagnoses. I do not universally disparage or praise the specialty based on my limited observations.

    It sounds like the NP at the UC needs some education in working up a fever without obvious cause in a child patient. Your sports physical example of an undescended testicle is more an indictment of the previous primary care. Most sports physical exams are not meant to be a comprehensive physical exam for the patient, especially in the context of the UC exam or a day clinic set up at an actual school. Did the parent notify the practitioner doing the exam of the previous testicle abnormality?

    I think the time is coming when UC’s will work hand in hand with PCP’s with appropriate triage and follow-up. More primary care will be enveloped into large health care systems (for good or bad) than ever before but there is an advantage of integrated care when the PCP, UC, ED and hospital system are on the same page.

    Until then patients must be encouraged to use their PCP whenever possible. We must also have incentives for appropriate use of the ED and UC centers with good communication and follow-up.

  4. Thanks for this. Sometimes it’s just hard to know what to do.

  5. You recommend the HPV vaccine????

  6. When my kids were little I always called my family doctor (I’m Canadian) & he would give me direction or meet me at the ER…they don’t meet nowadays but just sent you to the urgent care centre, ER or wait until morning. In my province urgent care is a step-down ER & I think what you call urgent care is our walk-in clinics. Your cases of mis-diagnosis happens here too. They just don’t know you or your kid.
    I volunteer in the ER dept of one of our hospitals and parents are still waiting until evening to do something about the fever/whatever the kid/baby has had since the early morning or earlier in the week(s). Or bringing them in for something that could wait until morning for their family doctor to see them. Then complain that they have to wait 2-6 hours to see a doctor! Sorry people but a rash your kid has had for a week and isn’t otherwise in distress (fever, vomiting, crying, in pain…) isn’t an emergency compared to the kid who is struggling to breath(or not at all), unusual crying from obvious distress over some unseen ailment, high fever, or has a possible broken limb. Or all of the above. (why are they waiting? It isn’t a money thing because these vists are insured fully for us…we pay for the meds that are prescribed so that could prevent some low income parents but even then they’re are ways around that if they’re honest with their doctor).
    I was a SAHM so I was the one monitoring my kids health and not doing it remotely when they were young. When they were teens i quizzed them on how they felt & did a judgement call or trusted their judgement if I couldn’t see them right then. They had pretty good judgement if they needed emergency care or not (even if the school staff didn’t have a clue at least someone kept their head!). I think it comes down to having some knowledge of the body, illnesses & a really good reference book and family/ped you trust and is accessible and knows your kid and you. I am so thankful for my early family doctors who were that way.

  7. I have a former micro preemie so I would never think of taking her anywhere but to see her regular pediatrician. However, I’m not sure that would be the case if she were a term kid. The reason why is that I’ve noticed there are barriers for patients to make use of the idealistic patient home.

    First, terrible office staff and policies make taking kids to the pediatrician more of a hassle than it should be. I often have to wait on hold for five minutes before I indicate that I need to make an appointment. Once I make my request known, I have to wait for a triage nurse to call back and schedule an appointment. That call usually comes one to two hours later. This is the amount of time I would have spent in urgent care.

    Second, in large practices… it is very difficult to see the same doctor. Yes, all the doctors in a practice are equally capable. It simplifies things when the same doctor regularly sees my child. I don’t have to recite her complicated medical history over again, the doctor knows what’s “normal” for my child, and it is easier to recognize when something isn’t right. I have to insist on my child seeing the same doctor each visit. If I wanted to see an unfamiliar doctor, I could more easily take her to urgent care.

    Third, scheduling can be tricky. Many times, there are not available appointments when needed. Again, it would be much easier to walk into urgent care and have a illness taken care of the same day.

    The medical home is a nice ideal. But, it takes a lot of time and energy to maintain my toddler’s medical home. I can understand how parents with children with out special needs would opt for urgent care. I can’t fault them for it. Most days, I don’t want to have to deal with the obstacles we face to see our regular pediatrician. I am not sure it would be worth it to me if it weren’t for her unique medical history.

    If you want patients to use a regular doctor instead of urgent care, address the issues that make urgent care an inviting option.

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