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John Shufeldt, MD, JD, MBA, FACEP
I just returned from Boston, where the American College of Emergency Physicians held its national conference. While there, along with learning (and relearning) some emergency medicine, I had the change to walk along the Freedom Trail and enhance my understanding of our battle for independence. What continually amazes me is how fortunate we were to actually succeed. Many times the only thing which turned the tide and saved the day was the persistence of our founders.

Many historians consider the Siege of Boston (starting after the battles of Lexington and Concord) to be the beginning of the Revolutionary War. During the siege, militiamen surrounded Boston, attempting to prevent the British Army, which was garrisoned with Boston, from receiving supplies. To fortify his army’s position and prevent the British Navy from supplying the British Army. General Washington sent a 25-year-old bookseller named Henry Knox to bring heavy cannons that had been captured at Fort Ticonderoga in New York all the way to Dorchester Heights, MA, which overlooked Boston’s harbor.

Over a wet and freezing winter, Knox and his small group moved 60 tons of artillery by boat, horse-drawn sledges (which they built), and sheer persistence 300 miles along snow-packed trails, across two semi-frozen rivers, and through forests and swamps to the Boston area in 56 days.

Historian Victor Brooks called Knox’s feat “one of the most stupendous feats of logistics” of the entire war. Ultimately, the effectiveness of these cannons marked the turning point which eventually forced the British out of Boston.

One of my favorite quotes from Calvin Coolidge:
“Nothing in this world can take the place of persistence. Talent will not; nothing is more common than unsuccessful people with talent. Genius will not; unrewarded genius is almost a proverb. Education will not; the world is full of educated derelicts. Persistence and determination alone are omnipotent. The slogan ‘press on’ has solved and always will solve the problems of the human race.”

You may be asking yourself, how is this relevant to urgent care medicine? More and more I am realizing the “secret sauce” which separates the failing (or, at best, marginally successful) business form the highly profitable endeavor is simply the persistence of the leadership team.

Urgent care medicine is engaged in our own Siege of Boston. There are a number of unknowns which will influence the eventual outcome of our new specialty. Retail clinics will eventually figure out how to turn a profit for their investors. When this happens, how much more of our current patient volume will be usurped by these groups? How will healthcare reform impact our business?

It seems logical that under any plan to reduce healthcare costs, urgent care should fair well. However, will we survive until that happens? How will our rates be affected? We are already at the low end of the reimbursement continuum and even trivial rate cuts could erase our already thin margins.

When will the malpractice insurers realize that urgent care medicine is a risky proposition and raise our premiums?

When will emergency departments improve their throughput and lower their cost to compete with urgent care centers and retail clinics?

So Mr. Know, what’s the game plan? How are we going to move the cannons and protect our already besieged turf? Here are some strategies to consider:

  • Don’t settle. Health plans are in business to make a profit for their shareholders. To accomplish this, they have three options:
  1. Charge higher rates.
  2. Reduce utilization.
  3. Pay providers less.

Out of these three, guess which one is the easiest? You guessed it, pit the providers against each other, and contract with the urgent care who will accept the least amount of reimbursement. Ever hear of divide and conquer? It is happening to us. How do we combat it without being accused of price fixing? Educate the plans on the value of contracting with urgent care centers and hold the line of reimbursement.

  • Practice quality medicine. What influences our malpractice rates? The collective industry malpractice experience. Therefore, if our industry has a disproportionate amount of adverse events, it will affect all of our rates, no matter our own center’s malpractice history.

I have the “benefit” of reviewing a large number of malpractice cases brought against urgent care centers all across the U.S. The cast majority are very preventable by following a few simple ideas: Urgent care centers (like emergency department) typically have “one-off” encounters where the tolerance for error is low. Therefore, protect yourself – and most importantly, the patient – by ruling out the things that will kill them.

I advocate using a liberal number of diagnostic tests. No one ever died from getting an unnecessary EKG, CXR, D-dimer, troponin, etc. We typically have one shot to get it right, so do what is necessary to assure yourself that the patient does not have an unusual presentation of a deadly condition.

  • Use standing orders. Important tasks and tests must not be overlooked during high volume times. Every malpractice case I have reviewed could have been easily prevented by using rational standing orders.
  • Use informed consent and document the conversation. Engage patients in their own healthcare. Appropriately documented informed consent is medicine’s equivalent to Monopoly’s “get out of Jail Free” card.
  • Invest in a state-of-the-art electronic records system. This will allow the provider to accurately record the patient’s treatment, discharge instructions, and informed consent. Let the patient take home an electronic or paper copy of the record so that they can share it with their personal physicians.
  • Stick together. Don’t denigrate your competitors despite what they may be saying. There will be enough people criticizing urgent care centers without us trash-talking our own. As Ben Franklin said, “We must hang together, gentlemen … else, we shall most assuredly hang separately.”

As a discipline, if we simply hold the line on reimbursement, practice quality medicine, and stick together we will enjoy the longevity that our specialty and our patient’s deserve.

In other words, we have to persist and thrive in the face of a myriad of challenges. So what happened to Henry Knox? He was repeatedly promoted and was eventually named the first Secretary of War. He went on to champion rights for Native Americans and later retired to Maine. Most importantly, his extraordinary accomplishments paved the way for our eventual independence.


John Shufeldt, MD, JD, MBA, FACEP

Chief Executive Officer at MeMD, LLC, Mentor and Author at Outliers Publishing, Principal at Shufeldt Consulting, Founding Partner of Shufeldt Law Firm
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