Retail clinics: power to the patient

If you’re a primary care doctor, as I am, you hear a lot of complaining about retail clinics, often denigrated as “doc in a box”, although most are staffed by Nurse Practitioners or Physician’s Assistants. Most commonly located in pharmacies (well, the hypertrophied pharmacies of national chains such as CVS and Walgreen’s), they have also appeared in other large retail stores such as Wal-Mart where thousands of people go every day expecting to get all that they need in one location. If you can get everything from food to big-screen TVs, car parts to drugs, why not health care?

The reason primary care doctors are concerned is that it more directly competes with what they do than what sub-specialists do. No one is (yet) worried that these clinics will do colonoscopy, not to mention cardiac catheterization or orthopedic surgery. Plus, the main “legitimate” argument against them from primary care physicians is the lack of continuity in this setting, and sub-specialists are not overly concerned with this issue. They do believe in continuity for the problem being treated if it is for a defined time (e.g., pre, during, post surgery) or longer-term for the problem that they care for (heart disease, cancer). But people are not using retail clinics for these things; they may go for blood pressure and glucose and cholesterol checks and refills of prescriptions for these conditions, but they are not expecting such clinics to manage complex disease. Hopefully.

In a recent “Viewpoint” in JAMA, Christine Cassel, an internist, geriatrician and ethicist who is at the American Board of Internal Medicine, writes about this topic in “Retail clinics and drugstore medicine”.[1] It is a generally positive review, noting how well such clinics meet the needs of busy people for fast, convenient and generally effective care. She notes that these clinics, in general, “…have a limited scope of services defined by widely accepted treatment guidelines for acute illnesses,” that “Many have extended hours and are open on weekends, have embraced electronic medical records, and refer patients to a primary care physician if they do not have one,” and that “Research done by third parties has suggested that clinics provide equal-quality care and lower costs than other settings. Reported patient satisfaction is high.” It seems to me that these are all good things; that we should be applauding such access to care. If we rue the transfer of income from ourselves and our institutions to the mega-corporations who run these clinics and hire the staff, it is understandable, but not in itself something we can expect others to be overly concerned with.

Dr. Cassel observes how these clinics help other health professionals, including pharmacists, work at the top of their license and skill set. She notes that while there still are problems with retail clinics, especially their integration with the rest of the health care system, they are making progress. Their corporate owners want them to be integrated, to be sure that they can continue to make money taking cash or insurance for diagnosis and treatment of straightforward problems that can be cared for in such settings, and can refer out for other problems.

The fact is that “integration”, or even communication, within the traditional health care system is much more the exception than the rule. We see patients who have been to the Emergency Department at another hospital who show us the “rest and see your doctor next week” paper that they were handed, with no information (lab, x-ray, even diagnosis) to help that doctor. We see patients who are seen in Mental Health Clinics from which we get no communication about diagnosis or why they are on the medications that they are taking (or even if the patient’s understanding about what medications they are taking is the same as the mental health provider’s). We see patients cared for by other doctors in our own institution who have yet to “go live” on the Electronic Medical Record (EMR) and we have no idea what was done. Indeed, the corporations running retail clinics in their stores appear to be much more willing to invest money in ensuring communication than are most of our medical institutions.

Rather than bemoaning such retail clinics and sitting around in the Doctors’ Lounge complaining about their deficiencies, we should be both welcoming them as partners who can help to meet the acute care needs of people who don’t have (or can’t get in to see) their primary care doctors, and figuring out ways to effectively communicate with them and share information. We should also be figuring out how we can adapt our own practices to incorporate some of their most desirable features. These include:

·       Quick access: what you need when you need it. It is much better to be seen for a minor problem for a relatively small amount of money in such a clinic than in an Emergency Room.

·      Clear pricing: virtually absent in every medical practice other than those sometimes called “cash only” or more negatively “boutique” or “concierge”. Remember that this doesn’t mean that we can only care for those with cash in their pockets; folks can send their bills to insurance companies (although those who are less able, due to illness, age, language, or other issues will need help)

·      Patient centeredness: our practices are almost always doctor-and-staff centered. If we ask ourselves about every aspect of our process and practice “how can this be made simpler, easier and faster for the patient” we will come up with answers. We should never accept “oh, that will be inconvenient for the doctor” as a reason to not change something, but rather figure out how to make it more feasible.

Training practices, with students and residents will have a harder time. The former need more time to learn what they are doing, and should only be observers in such settings. The latter, while they often have the skills (and employ them in “moonlighting” situations) are governed by many rules from their accrediting body that will often “trump” patient-centeredness.

But we need to do this. There are too few primary care doctors to meet everyone’s needs, we need teams, and we need everyone –including the doctors – to be operating at the “top of their license”. We cannot see retail clinics are not the enemy. Rather, we should see them as mirrors, providing us with a reflection of our own deficiencies, and information about how we can not only work together but improve our practices overall.

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[1] Cassel CK, “Retail clinics and drugstore medicine”, JAMA, May 23/30, 2012—Vol 307, No. 20, pp. 2151-2.