Opinion | The Pluses and Minuses of Adding More Services

How do we decide what we do, and what we don’t do, in an ambulatory primary care practice?

Many years ago, we had crash carts that we kept in each area of our practice, which is physically divided up into the Red, Green, and Blue practices. Each had a complete emergency setup, including all the medications necessary for advanced resuscitation and the stabilizing equipment needed in the event of a medical emergency. The problem was, these events were so few and far between at our practice, that essentially, the crash carts became just large, expensive boxes that stood around and eventually were found to have expired medications stored within them.

Over the first decade or so of my time in this practice, I can really remember only a few times when anything in the crash carts was actually needed. Once in a while it was the epinephrine for an allergic reaction, once or twice some adenosine for a semi-unstable patient with an arrhythmia. But otherwise, those big red crash carts took up a lot of floor space, got really dusty, and eventually just became something else for the Joint Commission to yell at us about.

What Makes the Most Sense?

Does even having the capacity to perform advanced medical interventions or lifesaving procedures make sense in the outpatient setting? Occasionally, we have had quite ill patients at our practice, and at this point, because the hospital has removed those crash carts, we do what we can with what we have, and work to stabilize patients until paramedics arrive. Even given the fact that the paramedics are nearby (our practice is located directly across the street from the main hospital with its fully staffed emergency department), the process of getting someone to come and pick up our patients sometimes takes a little longer than we would like.

Sure, while we are waiting, we can get an IV in and run some saline, get a patient’s fingerstick blood glucose reading, give some oxygen, chewable aspirin, albuterol nebulizer treatments. And a few years ago we bought some standard automatic electric defibrillators, which are mounted in each area of the practice, but thankfully we’ve only had to take one of these off the wall once.

For the most part, we can handle things, and over the past few months we’ve been working to design, standardize, and streamline a Rapid Response Team, similar to those on the hospital inpatient services, who get STAT paged to patients with a significant deterioration of their clinical status. This will include a couple of providers who are sort of “on call” for the day, equipped with a go-bag of the necessary equipment to handle most emergencies, with standard protocols.

What Limits Should There Be?

But trying to figure out what we should do at our practice, what we can do, and what others will let us do, can sometimes also be a challenge. When I first started working at this practice such a long time ago, we were still doing flexible sigmoidoscopies in the office, and all of the Internal Medicine residents rotating through could get certified through the course of their residency by doing a couple of procedures right there in our practice.

The mechanics and the complexities of doing this far outweigh the benefit, and very quickly these procedures were pulled from our setting and appropriately localized within Gastroenterology (although I can hardly remember the last time flexible sigmoidoscopes were used at all; virtually everybody gets a full colonoscopy these days. On a side note, I still have the original flexible sigmoidoscope that we used in a big case in a closet, could probably fetch a pretty penny on eBay, if anyone is interested…)

Way back then, there weren’t as many gastroenterologists around to do all the screening for all of our patients, and doing this procedure in our office was a reasonable part of primary care. But now it makes overwhelming sense to move this off site, to it put in the hands of a well-oiled machine over in the Gastroenterology department, with fully outfitted endoscopy suites and appropriate and safe monitoring of patients.

Over the years, different providers in our practice have taken an interest in doing different kinds of procedures, including wound care, incision and drainage of simple abscesses, suturing of minor lacerations, simple skin shave and punch biopsies, freezing of dermatologic lesions like warts, placement of IUDs and contraceptive implants, and joint injections and drainage. But sometimes, when we try to set up a program to do these comprehensively at our practice, someone somewhere decides that we’re stepping on their toes, invading their space, stealing their livelihood.

Is It the Right Thing to Do?

Clearly, we only want to do this if it’s the right thing to do for our patients, safe and easy to do, adds benefit to patient care, and expands the educational experiences available in our practice. In today’s environment of workforce shortages, as we struggle with getting patients in to see a specialist for a minor procedure, there are certainly opportunities for us to work collaboratively with others to get our patients what they need, when they need it.

Recently someone sent me an email about a patient we had referred to a subspecialist; initially the doctor was elated because the appointment the patient had been given was for April 29. Then they realized it was April 29, 2024.

I’m not suggesting that we take over the care of everything our specialist, subspecialist, and surgical colleagues do, but there are probably a lot of routine things that we can take off their hands and do well, which would help clear the backlog of appointments from our colleagues’ schedules. At the same time, we don’t want to overstep our boundaries.

A Rapid Response team may be an answer to help stabilize patients acutely, but we certainly don’t want to set up a step-down unit or an ICU in our practice. However, if tapping someone’s knee joint, finding out they have negatively birefringent crystals, and starting them on appropriate treatment for a gout flare can be done easily and safely in our practice, then maybe this makes sense. We will of course need support, resources, training, and education to get this done and do this well, but in the end it may be worth it to think about how we can expand what we do.

And as we begin to think about new and better ways to take care of patients, including remote patient monitoring, giving patients devices that can help them extend their care into the community, even offering services like point-of-care ultrasound in our practice to quickly make a diagnosis that would otherwise be delayed, I think the potential is nearly limitless, the opportunities are there, and we just need to reach out and grab them.