The 10 commandments of walk-in clinics

Walk-in (WI) clinics provide a much-needed escape valve for a backed-up health care system when used for their intended purpose, episodic care; commonly dealing with UTIs, STIs, minor injuries, migraines, URIs, rashes, and last-minute prescription repeats. It’s well known that family practices have more work per patient than walk-ins, hence the popularity of capitation models that provide better compensation. WIs are primarily paid by the lesser fee-for-service, which is fine when the work requires less time. The shortage of family practitioners (FP), patients choosing not to have one, and patient difficulty booking an appointment with the one they do have (worsened by the pandemic) has led to many WIs becoming de facto family practices. What do de facto family practice patients want? They want it all— screening, work up for multiple chronic problems, referrals— the whole shebang. And they often want it all at once. This saps the energy and resources of WI clinics and leads to stress and burnout for physicians and staff. Patients lose if they can’t get in for simple episodic problems or receive substandard pseudo family practice care. Read: Face it, we have a drug problem What can a WI doctor do to help their clinic get back to its intended purpose, while helping patients get healthcare delivered appropriately? These are my 10 commandments for letting patients come (but then go!): Note: please interpret ‘thou shalt’ as ‘try to.’ Thou shalt aim to have a high percentage of your patients under the care of an FP. If they don’t have one, help them find one. Try hard because the success of your clinic and your patients’ overall healthcare depends on it. Thou shalt not address chronic problems of those with an FP. There is usually no urgency. Temporize if necessary. Be nice but tell them firmly to book an appointment with their FP. Thou shalt not provide second opinions for patients who have an FP. If you want to give patients new insights, keep them brief and ask patients to review your ideas with their FP. Be warned, if a patient likes your assessment better, you may have unfortunately gained a new de facto family practice patient. Thou shalt not make referrals for patients with an FP. It’s the FP’s job and better for continuity of care. Thou shalt train thy patients to expect one problem addressed per visit (but don’t write this down anywhere as regulatory bodies don’t like it). List patient concerns and deal with as many problems as you wish. Obviously, some complaints are related. When you lower patients’ expectations they will be pleasantly surprised when they get more, not angry when they don’t get enough. Thou shalt not over-order tests. Inappropriate testing opens up a can of worms that shouldn’t be addressed in a WI setting (e.g.: screening tests such as cholesterol) and checking off too many boxes on the lab form. Reviewing test results you ordered is harder for your fellow WI colleagues unfamiliar with the patient, because they must review your (sometimes sparse) notes, and may need to redo part of the history/exam. If thou order tests, thou may redeem thyself by avoiding a management spiral. If a physician orders tests on a patient who has an FP, try not to let that precipitate more testing. When following up on bloodwork, etc. for chronic problems, email results to the patient and have them follow up with their FP. It’s never too late to correct the sin of an initiated work-up for a chronic problem. Thou shalt have patients follow up tests with the ordering physician where possible, such as non-urgent situations. Again, it’s easier for the ordering physician and better for (micro)continuity of the care of this particular patient/problem. Thou shalt not allow thyself to get dumped on. Sometimes FPs don’t want to do time or labour-intensive assessments and procedures. Sometimes they choose to only be available by phone. They may send these patients to your clinic. Examples are ear syringing, complicated dressing changes, and abdo pain assessment. Don’t let your WI nurse get turned into the local ear ‘syringologist’ for $10 a pop. Your clinic can choose what referrals it takes. Thou shalt not prescribe controlled substances. It’s difficult to determine the need without an ongoing relationship and you can drag colleagues into prescribing when you’re not on shift or leave the practice. Once you start prescribing, it can be hard to stop. In many locales you have no idea how many other practitioners are prescribing. Observing these ‘commandments’ is not all or nothing. Each application will move the needle slightly in the direction of bringing your WI clinic back to what it’s meant to do and paid for, episodic care. Your clinic will gradually become less rushed and stressed. Patients will understand your important yet limited role in their care. Read: The iPhone figured it out, why can’t my EMR? Dr. Jonathan Marcus is a family doctor in Toronto. He writes on practice management and healthcare technology. Check out is his blog The Omniverse. You can reach him at jonathan_marcus@mac.com.

The 10 commandments of walk-in clinics

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