Back in May 2009, I used this column to report on the start-up of an orthopaedic night clinic. Since then, the concept has been given many names, including after-hours clinic, orthopaedic minor med, and orthopaedic emergency clinic. Whatever it’s called, it has been wildly successful. Readers have written to me with their experiences, and I have been asked to comment on what we’ve learned during the past 2 years. So here’s some general advice, as well as a look at the pros and cons of this service.


Published 1/1/2012

Orthopods in the Night Pod

If you are available, they will come.

S. Terry Canale, MD

What you should know
The first lesson is NOT to call it an emergency, urgent care, or orthopaedic minor medical clinic. You do not want to imply that this is an emergency facility, because if you do, state regulations may required you to obtain a certificate of need (CON) and to comply with all the rules and regulations that apply to a hospital emergency room.

You will need some form of marketing to let your patients and the general public know about the clinic. If you don’t do this, you will be available but patients will not come because they won’t know that you’re there! We used radio and television advertisements during the early evening and late night local newscasts for about 9 months. But once you’ve established a level of awareness, you can reduce the heavy “blitz” of advertising.

As awareness grows, the patient load will increase and you must be prepared to expand both personnel and space. We now have added a second team (orthopaedist, physician assistant, X-ray, and cast technicians) to handle the volume of patients. Not a bad problem to have.

If your marketing message is clear, you should see patients with primarily musculoskeletal problems. Most problems we see are acute sprains, strains, or minor fractures. Rarely do patients try to register with nonorthopaedic problems (eg, asthma) or without insurance coverage.

We went from seeing an average of eight patients per night (during the hours of 5 p.m. to 8 p.m., Monday through Thursday) in 2009 to 30 to 60 patients per night in 2011 (Fig. 1), and it seems that this trend will continue. Although growth was progressive, the winter months show a slight dip.

I believe the after-hours clinic was responsible for much of the increase in the number of patients we saw (patient access), treatments delivered, and increased reimbursements.

Be prepared for problems
Although our experience has been basically positive, after-hours clinics can also have some negative aspects.

It may take a while for the clinic to get off the ground. For example, the demographics might not be right in your area (eg, your practice is owned by a hospital with an emergency department or minor medical clinic). Initially, you may see only a few patients and your overhead may be costly. Don’t be discouraged, this will improve rapidly (“they will come!”). When we first opened the after-hours clinic, just five or six patients would show up each night; our all-time low was one patient. But we persisted, and the graph shows the results.

Some practices may be too small to have or even want a night clinic. If a small office must also staff an after-hours clinic, the surgeons must work every 3 to 5 nights, compared to the 1 night a month required if the clinic is run by a larger practice. Smaller practices may consider some sort of merger, but this would require research and a legal agreement.

Similarly, support staffing may be hard to find. Even if they receive overtime pay, some employees don’t, for personal reasons, want to work past 5 p.m. Remember, the personnel needed are a doctor’s assistant or nurse, an X-ray technician, a cast technician, and a receptionist. In our office, each orthopaedic assistant or nurse works with his or her regular physician and they take the rotation together. The other personnel sign up for service on a voluntary basis. We include employees from all our office locations even though the after-hours clinic is held at only one location. Although staff receive overtime pay, their participation in the clinic is not “expected” or a condition of employment. It’s a complicated process with a large intial outlay, but “if you build it, they will come.”

Other potential personnel for the after-hours clinics are post-residency fellows, who may be assigned to work with specific orthopaedists according to their fellowship interests. Nonphysician providers, such as physician assistants and nurse practitioners, also can be helpful.

Naturally, if you are successful, you can expect competition from other orthopaedic groups, minor medical clinics, and hospital emergency departments. Be prepared to increase your marketing efforts or to expect a plateau in the number of patients you see if the competition “jumps in.”

You will need to provide more security at night. Patients may have consumed a bit too much alcohol or indigents may take advantage of your warm waiting room. We’ve even had a pizza delivered to the exam room while the physician was examining the patient. The patient had ordered the pizza while in the waiting room, and the delivery guy wanted to make sure his customer got it while it was still hot!

Occasionally a long-term clinic patient will slip past the receptionist’s desk, although we rarely see the patient with chronic low back pain and three failed surgeries in the after-hours clinic. When this occurs, you can triage the patient to see the appropriate consultant on the following day. We also see very few “drug-seeking” patients, and we will not see patients with nonorthopaedic problems, but we will refer them to the appropriate physician. Fortunately, most people can determine if they have a musculoskeletal injury and know that is all we see.

Finally, realize that although the sign-in time ends at 8 p.m., you may have to stay until 9:30 p.m. or 10:00 p.m. to see the last patients.

It’s a good thing
Now for some of the positives of an after-hours or night clinic.

  1. In all of medicine, the #1 priority is the patient. Night clinic gives the patient immediate access to treatment. The patient can be seen on the day of the injury and not be sent “down the street” because you can’t see him for 10 days.
  2. Also, it is “one-stop shopping,” enabling the patient to be seen by an orthopaedist first rather than being sent to the orthopaedist after a visit to a minor medical clinic. This reduces charges to the patient and makes the entire encounter more cost-effective. The patient receives high-quality treatment without an excessive wait or a delay in seeing a “consultant.”
  3. An after-hours clinic expands the reach of your practice. It “unlocks” your appointment desk so the acute patient can be seen on a “first-come, first-served” basis (no appointment necessary). This enables you to “capture” the patient and later refer him or her to the appropriate specialist in your group.
  4. An after-hours clinic can decrease the “new patient appointment” waiting list for your entire group. Although we can’t be sure about the numbers, night clinic does not appear to have lessened the number of patients in the regular day clinics. In fact, our day clinic patient visits have increased, in part due to the after-hours clinic and our cross-referral system.
  5. You may find that the night clinic is so popular that you have to expand it. We just added Saturday mornings (8 a.m.–11 a.m.) to enable us to treat, among other injuries, the “Friday Night Lights” football injuries.

As we look back on our history with an after-hours clinic, the only question we have is why didn’t we do this sooner!

After years in the practice of orthopaedics, I have learned that medicine has few win-win situations. Every drug and treatment has its beneficial effects but also its potentially harmful side effects. The night clinic is a win-win for the patient, for your practice, and for you. There is no better feeling for a physician than when helping a patient, especially one with an acute problem.

This may not be a “field of dreams,” but “if you build it” and are available, “they will come.”