Unique Challenges in Urgent Care Medicine

By:   August 23, 2016

By Arash Mirzaie, PA-C
MEDEX Yakima Class 16

The patient-provider relationship is unique in an urgent care setting. Providing care in this setting involves episodic interaction, without the advantage of previous and ongoing patient-provider contact that you might find with inpatient or behavioral medicine.

In urgent care, patients do not select their provider, and there is usually no prior relationship that exists between the patient and provider. In addition, patients and urgent care providers interact in a time-limited environment. Operating outside the traditional Emergency Room, urgent care centers primarily treat illnesses or injuries requiring immediate care, but nor serious enough for an ER. And where I work—in the culturally diverse Crossroads neighborhood of Bellevue, WA—the a number of patients who present to urgent care bring with them diverse cultural beliefs and ethical values that can differ from those of the provider.

Providing care in such a setting to patients from different background can create some unique challenges.

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It’s 5:00 pm, mid-July, and 90 degrees outside. My MA presents the next case to me. In Room 3 is a 63-year-old female with a headache and dizziness. I review patient’s vital sings right away: BP: 90/64, Pulse: 110, Temp: 99.3. Positive past medical history of diabetes on Metformin, as well as hypertension and hyperlipidemia. I go to the exam room and see an older woman sitting on the chair, resting her head against the wall. She’s wearing a headscarf, looking pale. There’s a younger female sitting next to her, also wearing a scarf. Having grown up in the Islamic state of Iran, I recognize that the women are Muslim.

“Hi, my name is Arash Mirzaie. I am a physician assistant. I’ll be seeing you today. Is that all right?”

“Sorry, we don’t speak English well,” the younger woman says.

“It’s alight, English is my second language as well,” I tell her with a big smile. My guess is that they are immigrants from North Africa, or perhaps Somalia. “Please let me know if I need to speak slower, or if you want me to repeat a question. Okay, tell me, why are you here today?”

The younger woman tells me that the older woman is her mom, and that she has not been feeling well since this afternoon, complaining of headache and dizziness. “She also been shivering and having cold sweats off and on,” the daughter reports.

I continue with the history and review of systems. “When was the last time your mom ate?” I ask. She responds, “My mom is actually fasting.”

Although I was raised in the Bahá’í Faith, I am familiar with the Muslim tradition of fasting during the holy season of Ramadan, when devotees abstain from food and water during daylight hours. I further investigate what their fasting involves. The patient’s daughter says that they ate breakfast prior to sunrise, and won’t eat or drink anything until after sunset.

Muslim Woman Low-ResI help patient to get on the table. Physical exam reveals a lethargic, pale, weak female. Dry eyes, lips, and oral mucosa. Chest exam reveals regular tachycardia, lung clear with auscultation. Normal neuro exam, except generalized weakness. The patient’s blood sugar level is then checked, and found to be 56. In contrast, before meal normal sugars are 70 to 99 mg/dl.

I then explain my findings to educate the patient and her daughter. I advise intravenous fluid therapy and oral glucose beverage.  The patient’s daughter translates this for her mother. As they speak in their native language, I watch the mother’s facial expression, frowning, and see her shaking her head as if to say, “Are you kidding?” I ask what the problem is. The daughter tells me that the two of them are fasting for religious reasons, and should not eat or drink anything until after sunset.

I acknowledge my understanding of the patient’s concern and beliefs. However, I reinforce the significance of the mother’s illness, and the possible complications if she refuses treatment. The daughter speaks to her mother again, and she still refuses.

I’m not sure what to do at this time. I know that patients have the right to refuse any treatment. But I don’t want to just accept this. It would require having them sign an AMA (Against Medical Advise), absolving the medical facility of any liability in the event of a resulting complication. I know that if this patient leaves the clinic, she may end up with severe hypoglycemia and further complications like coma.

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Arash Mirzaie outside his workplace, The Immediate Clinic, in the Crossroads neighborhood of Bellevue, WA.

I explain this to the patient and her daughter once more. I ask the patient’s daughter to tell her mother that this is very significant. The patient then asks me several questions, which I answer.

After several minutes of talking, the patient states that she will proceed with the treatment. I then ask the patient’s daughter to translate the following for her mom: If, one day, God questions her about this incident, direct him to me. Once the daughter translates, the patient looks at me with a big smile.

The patient is then given IV fluid and oral glucose beverage, which improves her symptoms significantly.

I believe what made a difference with this patient is that she felt appropriately understood and honored for her spiritual and cultural beliefs. Even though my medical advice ran contrary to her religious practice, I made room for this in the conversation while offering her an argument that favored her health and well-being.

As urgent care providers we rapidly evaluate, intervene, and diagnose a variety of illnesses, including life threatening ones, among a variety of populations across different cultures. This experience taught me that shared decision-making can still be an important part of urgent care medicine, especially when it comes to cross-cultural situations. Although the urgent care environment poses challenges to communication and decision-making, shared decision-making is feasible and offers benefits to patients in this setting.

Arash Mirzaie, PA-C is a graduate of MEDEX Yakima class 16. Since graduating in 2011, he has been working in an Urgent Care center in Bellevue, WA. He treats patients from all age groups with various medical complaints. Arash can be reached at arashm@uw.edu or through MEDEX Northwest at 206 616-2001.

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Arash Mirzaie, PA-C is a graduate of MEDEX Yakima Class 16 from 2011. He is an urgent care provider in Bellevue, WA. He can be reached at arashm@uw.edu.