Urgent care centres: proceed with caution.

The emergence of urgent care centres in the United States signifies an innovative response to the demands-public, private and governmental-to control the rising costs of health care. What is immediately obvious to the practitioner, however, may or may not be quite so obvious to the consumer. Simply expressed, trade-offs must be made. In the accompanying article 'Urgent Care Centres', Drs Janiak and Gray astutely described what has been gained by trading, but omitted what has been lost in the exchange. Although there is probably some truth in describing physicians as often the last to accept what is already obvious, the vast majority of physicians react with concern to anything that threatens a system already providing satisfactory patient care. Urgent care centres represent just such an innovative threat. The hesitation among physicians to accept the freestanding facility has been fuelled by what the authors themselves describe as 'business techniques such as advertising and marketing to attract patients'. If this had been done to improve the alleviation of pain and suffering, there would be no outcry. What resulted, however, was a 'bandwagon effect' where patients sought a professional, convenient and inexpensive alternative to the busy, bustling environs of the hospital-based emergency unit where delays were frequent, care inconsistent, and costs high. In many instances they were rewarded, in others, turned away because the rendering of 'emergency care' was based solely on the patients ability to pay. The end result was a movement by paying patients to the urgent care centres and an increase in the non-pay burden on the hospitals and hospital-based emergency facilities. Perhaps central to the issue is the authors' own definition of the private practice of emergency medicine. Is it valid? Can one, in fact, establish a private practice of emergency medicine? There are certain very obvious concerns with this concept. What happens to the 'emergency patient' who has no money, no insurance coverage, no endorsement? Is he to be excluded or transferred somehow (and at whose risk?) to the hospital-based emergency facility? Who is responsible for an adverse outcome under such circumstances? Can we expect patients to determine for themselves what is truly a 'relatively minor' affliction, and suitable for ambulatory care, from the lifeor limbthreatening problem requiring immediate sophisticated care and monitoring? How