Good Primary Care Resources

[The Knife & Gun Club]

I’ve been moonlighting in an urgent-care type setting a lot recently, but because of the way that particular health system is set up I end up seeing a lot of people for more PCP-y stuff. The challenge of the system is it takes FOREVERRRRR to get followup or establish care with a real PCP or see a specialist - usually 4-6 months.

So this leaves me with a bunch of people presenting to the urgent care setting for things that are really better managed by a PCP.

Do you all have any resources you’d recommend for nuts and bolts PCP stuff that I can do just to be sure I’m doing things correctly until the real PCP can step in?

Examples would be:
Pt with an echo showing new, non-decompensated heart failure. Should I start GDMT? If so, how and with which agents? When should they follow up? And if so what exactly am I assessing for on followup

Patient who was on Coumadin for lupus anticoagulant/APLAS with PE 15 years ago, off all thinners for 6 months. Saw now-retired heme onc in our system a decade ago who said Pt requires lifelong Coumadin. How do I bridge someone onto Coumadin from nothing outpatient? What INR should I target?

8 month pregnant female with no prenatal care. Won’t be able to get into see OB before she delivers. What are the normal prenatal screening labs. Wtf do I do if one comes back abnormal?

Patient with DM2 now failing metformin. Do I add a second agent? Start insulin? If so, what second agent?

Patient with hypertension refractory to 3+ meds. Do I just keep adding meds forever? I vaguely recall from med school you ultrasound the kidneys at some point…

Up to date and stat pearls is what I’ve been using which does an OK job but I’d like a bit more definitive for the nitty gritty stuff.

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[Lexdiamondz]

Absolutely none of the aforementioned things belong in an urgent care. You're doing too much, bro.


There's a reason why family medicine is a 3 year residency. It would be a cold day in hades before you catch me titrating someone's third antihypertensive or assuming care for a 3rd trimester pregnancy in urgent care.

 

[RustedFox]

Absolutely none of the aforementioned things belong in an urgent care. You're doing too much, bro.


There's a reason why family medicine is a 3 year residency. It would be a cold day in hades before you catch me titrating someone's third antihypertensive or assuming care for a 3rd trimester pregnancy in urgent care.

Yeah, this.
BuT a NuRsE pRacTiTiONeR can do it fresh out of the box with no training.

 

[Dr Mantis Toboggan]

I’ve been moonlighting in an urgent-care type setting a lot recently, but because of the way that particular health system is set up I end up seeing a lot of people for more PCP-y stuff. The challenge of the system is it takes FOREVERRRRR to get followup or establish care with a real PCP or see a specialist - usually 4-6 months.

So this leaves me with a bunch of people presenting to the urgent care setting for things that are really better managed by a PCP.

Do you all have any resources you’d recommend for nuts and bolts PCP stuff that I can do just to be sure I’m doing things correctly until the real PCP can step in?

Examples would be:
Pt with an echo showing new, non-decompensated heart failure. Should I start GDMT? If so, how and with which agents? When should they follow up? And if so what exactly am I assessing for on followup

Patient who was on Coumadin for lupus anticoagulant/APLAS with PE 15 years ago, off all thinners for 6 months. Saw now-retired heme onc in our system a decade ago who said Pt requires lifelong Coumadin. How do I bridge someone onto Coumadin from nothing outpatient? What INR should I target?

8 month pregnant female with no prenatal care. Won’t be able to get into see OB before she delivers. What are the normal prenatal screening labs. Wtf do I do if one comes back abnormal?

Patient with DM2 now failing metformin. Do I add a second agent? Start insulin? If so, what second agent?

Patient with hypertension refractory to 3+ meds. Do I just keep adding meds forever? I vaguely recall from med school you ultrasound the kidneys at some point…

Up to date and stat pearls is what I’ve been using which does an OK job but I’d like a bit more definitive for the nitty gritty stuff.

This moonlighting gig is terrible and aren’t you in a bad medmal state like Florida? Run away.

 

[n2b8me]

For HTN med mgmt:

https://kpcmi.org/files/blood-pressure-clinician-guide-kpcmi.pdf

For DM meds:

https://diabetesed.net/wp-content/uploads/2021/12/ADA-2022-Pharmacologic-Management-of-Type-2-PDF.pdf

For CHF I think academics refer to the 2022 AHA heart failure guidelines:

https://www.ahajournals.org/cms/asset/7fa4aa61-0a82-4949-9ad4-e458afba3d20/cir.0000000000001063.fig14.jpg

 

[VA Hopeful Dr]

I’ve been moonlighting in an urgent-care type setting a lot recently, but because of the way that particular health system is set up I end up seeing a lot of people for more PCP-y stuff. The challenge of the system is it takes FOREVERRRRR to get followup or establish care with a real PCP or see a specialist - usually 4-6 months.

So this leaves me with a bunch of people presenting to the urgent care setting for things that are really better managed by a PCP.

Do you all have any resources you’d recommend for nuts and bolts PCP stuff that I can do just to be sure I’m doing things correctly until the real PCP can step in?

Examples would be:
Pt with an echo showing new, non-decompensated heart failure. Should I start GDMT? If so, how and with which agents? When should they follow up? And if so what exactly am I assessing for on followup

Patient who was on Coumadin for lupus anticoagulant/APLAS with PE 15 years ago, off all thinners for 6 months. Saw now-retired heme onc in our system a decade ago who said Pt requires lifelong Coumadin. How do I bridge someone onto Coumadin from nothing outpatient? What INR should I target?

8 month pregnant female with no prenatal care. Won’t be able to get into see OB before she delivers. What are the normal prenatal screening labs. Wtf do I do if one comes back abnormal?

Patient with DM2 now failing metformin. Do I add a second agent? Start insulin? If so, what second agent?

Patient with hypertension refractory to 3+ meds. Do I just keep adding meds forever? I vaguely recall from med school you ultrasound the kidneys at some point…

Up to date and stat pearls is what I’ve been using which does an OK job but I’d like a bit more definitive for the nitty gritty stuff.

Yeah this is way beyond what you should be doing in urgent care.

That being said, go here: Patient Care

 

[CoolDoc1729]

I’ve been moonlighting in an urgent-care type setting a lot recently, but because of the way that particular health system is set up I end up seeing a lot of people for more PCP-y stuff. The challenge of the system is it takes FOREVERRRRR to get followup or establish care with a real PCP or see a specialist - usually 4-6 months.

So this leaves me with a bunch of people presenting to the urgent care setting for things that are really better managed by a PCP.

Do you all have any resources you’d recommend for nuts and bolts PCP stuff that I can do just to be sure I’m doing things correctly until the real PCP can step in?

Examples would be:
Pt with an echo showing new, non-decompensated heart failure. Should I start GDMT? If so, how and with which agents? When should they follow up? And if so what exactly am I assessing for on followup

Patient who was on Coumadin for lupus anticoagulant/APLAS with PE 15 years ago, off all thinners for 6 months. Saw now-retired heme onc in our system a decade ago who said Pt requires lifelong Coumadin. How do I bridge someone onto Coumadin from nothing outpatient? What INR should I target?

8 month pregnant female with no prenatal care. Won’t be able to get into see OB before she delivers. What are the normal prenatal screening labs. Wtf do I do if one comes back abnormal?

Patient with DM2 now failing metformin. Do I add a second agent? Start insulin? If so, what second agent?

Patient with hypertension refractory to 3+ meds. Do I just keep adding meds forever? I vaguely recall from med school you ultrasound the kidneys at some point…

Up to date and stat pearls is what I’ve been using which does an OK job but I’d like a bit more definitive for the nitty gritty stuff.

I get why you’re trying to do this, and I do the same thing.
It’s so frustrating when we are the only doctors these folks can find their way to. Due to lack of resources I end up doing goofy stuff I never would have done pre covid, because I feel like I want to do my best for each person I’m working with. On the other hand I want to continue to live in my house and I do not want to spend the next decade in court. I’m clearly not trained to manage prenatal care or titrate fourth antihypertensives. I’m sure it will be really easy to find a boomer EP who retired in 2019 to testify about the standard of care, even though he practiced when we had nurses and ambulances and Ativan and lidocaine. Urgh

 

[turkeyjerky]

It's an Urgent Care? Pfft, easy peasy. Just send them to the ER!

 

[BoardingDoc]

Examples would be:
Pt with an echo showing new, non-decompensated heart failure. Should I start GDMT? If so, how and with which agents? When should they follow up? And if so what exactly am I assessing for on followup

Patient who was on Coumadin for lupus anticoagulant/APLAS with PE 15 years ago, off all thinners for 6 months. Saw now-retired heme onc in our system a decade ago who said Pt requires lifelong Coumadin. How do I bridge someone onto Coumadin from nothing outpatient? What INR should I target?

8 month pregnant female with no prenatal care. Won’t be able to get into see OB before she delivers. What are the normal prenatal screening labs. Wtf do I do if one comes back abnormal?

Patient with DM2 now failing metformin. Do I add a second agent? Start insulin? If so, what second agent?

Patient with hypertension refractory to 3+ meds. Do I just keep adding meds forever? I vaguely recall from med school you ultrasound the kidneys at some point…

What in the hell are you doing? I understand from the beginning of your post that you're just trying to do right by people in a system that routinely takes them forever to see their PCP. That said, A: this is not your job, and B: you don't know how to do this job. Trying to fill the role of a PCP out of an urgent care is not going to end well for you.

I would get involved with literally ZERO of these patients that you've mentioned.

CHF patient? Who did the echo? Refer back to them.

Coumadin lady? Refer to whoever was prescribing her the thinners 6 months ago.

Pregnant woman? Are you seriously getting involved in this?! List of OBs in the area with instructions to call same day and explain the situation.

DM patient? Refer back to whoever is Rxing the metformin.

HTN? See above.

All of the above: THIS IS NOT AN URGENT CARE PROBLEM. YOU ARE NOT A PCP. Trying to do these things out of an urgent care is well beyond your scope of practice and there would be a line of doctors willing to testify to that fact in court. They wouldn't be wrong either.

 

[VA Hopeful Dr]

What in the hell are you doing? I understand from the beginning of your post that you're just trying to do right by people in a system that routinely takes them forever to see their PCP. That said, A: this is not your job, and B: you don't know how to do this job. Trying to fill the role of a PCP out of an urgent care is not going to end well for you.

I would get involved with literally ZERO of these patients that you've mentioned.

CHF patient? Who did the echo? Refer back to them.

Coumadin lady? Refer to whoever was prescribing her the thinners 6 months ago.

Pregnant woman? Are you seriously getting involved in this?! List of OBs in the area with instructions to call same day and explain the situation.

DM patient? Refer back to whoever is Rxing the metformin.

HTN? See above.

All of the above: THIS IS NOT AN URGENT CARE PROBLEM. YOU ARE NOT A PCP. Trying to do these things out of an urgent care is well beyond your scope of practice and there would be a line of doctors willing to testify to that fact in court. They wouldn't be wrong either.

I worked in an urgent care some years back and I wouldn't have managed any of that from there despite my FM training.

 

[TooMuchResearch]

Don't do those things at urgent care. This is the best adviSe I can offer.

 

[TeddyBoomBoom]

I would nope the F away from that in a heartbeat.

 

[The Knife & Gun Club]

I see what y’all are saying - sounds like I’m trying to do too much and probably need to draw the line on some of these cases and not f around with stuff that’s out of my depth, even if the person goes uncared for for a while longer or maybe has a worse outcome.

It’s useful to hear from some people who have worked urgent care style jobs in the past and the crazier stuff is decidedly out of scope.

The specifics of the job are tough to get into here but one silver lining is I do have sovereign immunity so at least can’t get financially ruined, although could still get sued and have a mark on my record.

 

[The Knife & Gun Club]

What in the hell are you doing? I understand from the beginning of your post that you're just trying to do right by people in a system that routinely takes them forever to see their PCP. That said, A: this is not your job, and B: you don't know how to do this job. Trying to fill the role of a PCP out of an urgent care is not going to end well for you.

I would get involved with literally ZERO of these patients that you've mentioned.

CHF patient? Who did the echo? Refer back to them.

Coumadin lady? Refer to whoever was prescribing her the thinners 6 months ago.

Pregnant woman? Are you seriously getting involved in this?! List of OBs in the area with instructions to call same day and explain the situation.

DM patient? Refer back to whoever is Rxing the metformin.

HTN? See above.

All of the above: THIS IS NOT AN URGENT CARE PROBLEM. YOU ARE NOT A PCP. Trying to do these things out of an urgent care is well beyond your scope of practice and there would be a line of doctors willing to testify to that fact in court. They wouldn't be wrong either.

Most of the people are return visits from the stuff ordered by the insane NPs at the same site. They’ll order all sorts of crazy stuff then be off when the patient comes back to follow it up so they just end up following up with me.

It can be very frustrating to get a follow up for a person who keeps coming back to this same clinic NP to get d dimers trended for a chronic DVT, and I’m just the guy unlucky enough to be covering the day they come in “because their dimer spiked”.

 

[thegenius]

I’ve been moonlighting in an urgent-care type setting a lot recently, but because of the way that particular health system is set up I end up seeing a lot of people for more PCP-y stuff. The challenge of the system is it takes FOREVERRRRR to get followup or establish care with a real PCP or see a specialist - usually 4-6 months.

So this leaves me with a bunch of people presenting to the urgent care setting for things that are really better managed by a PCP.

Do you all have any resources you’d recommend for nuts and bolts PCP stuff that I can do just to be sure I’m doing things correctly until the real PCP can step in?

Examples would be:
Pt with an echo showing new, non-decompensated heart failure. Should I start GDMT? If so, how and with which agents? When should they follow up? And if so what exactly am I assessing for on followup

Patient who was on Coumadin for lupus anticoagulant/APLAS with PE 15 years ago, off all thinners for 6 months. Saw now-retired heme onc in our system a decade ago who said Pt requires lifelong Coumadin. How do I bridge someone onto Coumadin from nothing outpatient? What INR should I target?

8 month pregnant female with no prenatal care. Won’t be able to get into see OB before she delivers. What are the normal prenatal screening labs. Wtf do I do if one comes back abnormal?

Patient with DM2 now failing metformin. Do I add a second agent? Start insulin? If so, what second agent?

Patient with hypertension refractory to 3+ meds. Do I just keep adding meds forever? I vaguely recall from med school you ultrasound the kidneys at some point…

Up to date and stat pearls is what I’ve been using which does an OK job but I’d like a bit more definitive for the nitty gritty stuff.

These are all EXCELLENT PRIMARY CARE QUESTIONS!!!!!

 

[Janders]

So I could be talked into starting a second oral DM med or adding a 3rd HTN med in a pinch. Hell I’ve started people on lantus from the ED. All of this could be reasonably within our capability.

BUT its always with a VERY TIGHT SHORT INTERVAL FOLLOWUP PLAN. I.E. if they don’t have a PCP, and can’t find one, and you don’t know any PCPs trying to build a practice see if you can find a (new!) cardiologist, endocrinologist, or nephrologist building a practice within driveable distance. Get a couple of these aces up your sleeve to refer patients to. If you don’t know any, just cold call some local hospitals, email CMOs, ask who wants referrals…

Its not too hard to learn the basic BP / DM meds, and you can always self-refer for the patient to come back to your UC in 2 weeks for repeat labs and recheck. I think these are reasonably low risk. I think it would be important you explain/chart that you’re really just bridging a gap for the patient and they need XYZ long term specialist followup for best management, but you’re going to try and help them in the short interval. Don’t be a hero, just basic stuff.

But the other stuff? 3rd trimester no care? If OB won’t touch it I’d refer to an ER with an attached L&D. New onset heart failure, that gets a cards referral!

With regards to starting someone back on anticoag who just went off b/c they stopped taking their meds and now wants back on… I’ve TOTALLY done that from the ED. Granted now a days its usually eliquis which is easy. But in training we routinely discharged people with a week of Lovenox bridge with Coumadin 5mg daily and a referral to Coumadin clinic for INR checks. I’d do that from UC, no issue. If you don’t have a Coumadin clinic to refer to though…

All that said…
You need to get to the root cause of this. This is an UC that is part of a big health system? Someone in admin is interested in CAPTURING THESE PATIENTS. You need to find those bean counters, explain to them how you’ve struck gold! A ton of patients that NEED care in their system but are way outside your capability, but boy-o-boy can you refer tons of them into the system if you just had a way to get care expedited a bit…

 

[emergentmd]

I’ve been moonlighting in an urgent-care type setting a lot recently, but because of the way that particular health system is set up I end up seeing a lot of people for more PCP-y stuff. The challenge of the system is it takes FOREVERRRRR to get followup or establish care with a real PCP or see a specialist - usually 4-6 months.

So this leaves me with a bunch of people presenting to the urgent care setting for things that are really better managed by a PCP.

Do you all have any resources you’d recommend for nuts and bolts PCP stuff that I can do just to be sure I’m doing things correctly until the real PCP can step in?

Examples would be:
Pt with an echo showing new, non-decompensated heart failure. Should I start GDMT? If so, how and with which agents? When should they follow up? And if so what exactly am I assessing for on followup

Patient who was on Coumadin for lupus anticoagulant/APLAS with PE 15 years ago, off all thinners for 6 months. Saw now-retired heme onc in our system a decade ago who said Pt requires lifelong Coumadin. How do I bridge someone onto Coumadin from nothing outpatient? What INR should I target?

8 month pregnant female with no prenatal care. Won’t be able to get into see OB before she delivers. What are the normal prenatal screening labs. Wtf do I do if one comes back abnormal?

Patient with DM2 now failing metformin. Do I add a second agent? Start insulin? If so, what second agent?

Patient with hypertension refractory to 3+ meds. Do I just keep adding meds forever? I vaguely recall from med school you ultrasound the kidneys at some point…

Up to date and stat pearls is what I’ve been using which does an OK job but I’d like a bit more definitive for the nitty gritty stuff.

Stick with this rule. If it takes more than 2 min, give them some clinic referral or send them to ER. Don't go outside these meds - Zpak, ultram, flexeril, prednisone or similar.

If the meds you are prescribing typically requires a refill, then likely best not to prescribe it.

 

[emergentmd]

Most of the people are return visits from the stuff ordered by the insane NPs at the same site. They’ll order all sorts of crazy stuff then be off when the patient comes back to follow it up so they just end up following up with me.

It can be very frustrating to get a follow up for a person who keeps coming back to this same clinic NP to get d dimers trended for a chronic DVT, and I’m just the guy unlucky enough to be covering the day they come in “because their dimer spiked”.

So they are essentially saying you are equivalent to an NP? Time to find a different job.

 

[InternistDO]

I think what you're doing is the equivalent of me trying to look up resources to manage a pregnant trauma patient as a general internist. You might be able to BS your way through using some online resources, especially for things like second line DM meds which are more simple, but eventually you're going to have a bad outcome (in the same way I would, very quickly, if I worked in an ED), whether from a malpractice standpoint or a patient harm standpoint, or both.

It's frustrating to not be able to provide care for people who need it, but in the long run these people need a trained primary care physician. Even if the care you provide is correct, are you going to be around at this job for long enough or often enough to manage their followup? I'd ask yourself if this job is really worth the possibility of being sued over or being responsible for a patient death or injury over something where you're clearly out of your depth.

 

[Brigade4Radiant]

lol next thing you know you are answering Mychart messages. I can't believe PCPs actually do that

 

[EthylMethylMan]

I've never done primary care, nor do I routinely chat with PCPs, but EMRAP's Right on Prime podcast seems solid from the bits I've listened to out of curiosity. But I'm gonna echo most of what everyone else is saying, probably should just not go anywhere near doing PCP stuff. Closest I get is writing someone a couple weeks of an antihypertensive to bridge them to seeing their regular PCP.

 

[BJJVP]

I understand what you are going through as I am in a somewhat similar situation myself. I get why you are stretching yourself and comfort level. However, my experience has been that the PCPs don't necessarily appreciate your work and may even tell you ,"You started it, so now you're stuck with it." My own PCP colleagues have told me don't do it. When an individual tries to overcompensate for a bad system, there is no incentive for the system to be fixed.

 

[Fluidity of Movement]

Curious to hear what you did next. It's been a rollercoaster for me following the thread. I love the idea of having some tough cases and going online to help figure them out, but sometimes it seems that isn't always plausible.

Did you figure any of them out, or did you give referrals?

 

[The Knife & Gun Club]

I switched to referring people and when I can physically calling the offices of the various specialists to try to speed up the time they can be seen.

And the really challenging/sketchy ones I just have them come back regularly for short interval follow ups so I can at least be sure they’re still OK and not decompensating until they can get into a real PCP or specialist.

And trying to be firm that if the NPP is around that ordered the weird test they have to be the one that sees them lol.