Against retail clinics

One of my recurring bugbears is the steadily-blurring line between patients and customers.  The expectation for customers at the end of a transaction is that they be satisfied, and everyone knows the axiom about them always being right.  A patient, on the other hand, is supposed to be treated.  While I would always hope that, when all is said and done, well-treated patients would consider themselves satisfied as well, sometimes it’s not so tidy, and often patients want things that I don’t think they need.  Balancing these competing pressures is one of the most challenging aspects of patient care, at least in my experience.

Perhaps it is no surprise that I am no great fan of so-called “minute clinics,” also known as “retail” or “urgent-care” clinics.  I think they are a bad idea for a whole host of reasons.

The first and most obvious reason to avoid them is that they have no access to a patient’s medical record, and thus their medical history.  They don’t know what medication allergies a patient has, what medications they’re taking, and what medications may have been tried already for any particular complaint.  Now, one might argue that patients should know all of this about themselves and thus be able to inform the providers at a retail clinic about what they need to know.  Sadly, patients often don’t know this information about themselves.  I can’t tell you how many times I’ve asked a patient if they’re allergic to anything, been told they were not, and then seen in the record that they are actually allergic to the medication I was about the prescribe.  Providers who try to deliver care without a reliable medical record run the risk of making avoidable errors.

Partly for the above reason and partly for the reason I’ll get to next, I’ve observed that the care delivered at these clinics is sub-par.  I know this is a generalization, and doubtless there are many providers at these clinics who practice good medicine.  However, far more often than not the patients who return to my office for follow-up care after having visited one of them have been put on medications they didn’t need (typically antibiotics) for infections they didn’t have.  I greet each new prescription for Zithromax (an antibiotic whose spectrum of activity is too broad for it to be used liberally when other, narrower-spectrum antibiotics will do, and the over-use of which is the hallmark of a lazy doctor) with a weary sigh.

Why do these clinics seem to hand out these medications like they were candy?  Because to them, patients are customers.  Their relationship is wholly transactional, and their goal weighted toward the satisfactory delivery of a requested service.  While I have no doubt that providers there have some standard of care their seek to meet, I question whether the context of their patient interactions makes best practices possible.  It is much easier and faster to write out the implicitly desired prescription than it is to explain why doing so is not in the patient’s best interests.  Some patients will be unhappy with being told they’re not getting a medication, and letting them leave dissatisfied is inconsistent with the mission of a retail clinic.

The dynamic is different for patients at a primary care office.  The relationship, at least ideally, is one of mutual respect and trust.  At my practice, we have worked very hard to establish a reputation of excellence, and we hope that patients take that into account when we give them advice that may not be what they want to hear.  As patients and families come to us over time, they see that we take good care of them, and so even if they leave without what they came in seeking they have invested enough with us to trust that we are making the best clinical decision we can.  There is nothing analogous in the setting of a minute clinic.

All of this came to mind upon reading this post by Aaron Carroll (via Andrew Sullivan) about why he would go to such a clinic:

There are times when you need to see a health care professional early in the morning, or later at night. Have you tried to get an appointment lately when you’re sick? It’s hard! That’s not all. You often have to wait a while.

[snip]

Almost two thirds of Americans have trouble getting care on nights, weekends, and holidays. You know what? A significant amount of the week is filled with nights, weekends, and holidays. Especially if you don’t want to miss work.

It’s fine to believe that people should try and see the doctor in the office. But if you want that to happen, then you need the office to be available. If retail clinics do a much better job in that respect, you can’t complain when people make use of them. In my example, my kids could be seen at 8AM, before school, without an appointment. That’s useful. If physician offices want that business, they should do the same.

There’s a lot to this, some of which I understand, and some of which gives me pause.  My perspective is a little bit skewed, in that in both my current job and my previous I worked for practices that made accessibility a major priority.  My current practice has walk-in hours every weekday morning from 7-8, is open until 7 PM every weeknight, has office hours every Saturday morning and we are even available (to a limited extent) on weekends and holidays.  I have to agree that waiting a week for an appointment for an acute illness is totally unacceptable (and would be curious to know in comments if many people have had the experience of being made to wait that long for a sick visit).

And yet, even with as much accessibility as we provide, a small number still go to minute clinics because they are momentarily more convenient.  I suspect an attitude similar to something Carroll briefly indicates in his post, when he mentions not wanting to miss work for a doctor’s visit.  While I grok that nobody wants to miss work… well, maybe sometimes that’s a choice you should make.  When I’ve needed legal advice, I’ve had to miss work to visit my lawyer.  Lord knows, if you have a plumber who’s willing to work around your work schedule, you’d better hold onto his number like it’s gold.  Why would seeing the provider who is most likely to deliver better care a consideration that takes a backseat to convenience?

Obviously, there are times when something just can’t wait (though I’d gently suggest that non-emergent care can almost always wait until morning).  I’m not arguing that there’s absolutely no role for acute-care clinics, though I’d generally favor those affiliated with well-regarded medical centers as opposed to retail outlets.  But if the option exists to wait a little bit to see the provider who knows you best and who has the best information about you at hand, isn’t that worth prioritizing?

41 thoughts on “Against retail clinics

  1. One of the things I’ve thought is an indicator of, well, of *SOMETHING* is the fact that there are commercials for dentists on television and commercials for optometrists (well, glasses factories with on-site optometrists, anyway).

    This tells me that, hey, these guys need more patients than they currently have (why waste the money on advertising?) which means that, somewhere, there is a (perhaps small) surplus of health care.

    Is this a function of the type of health care they give? Like, there’s only so many ways that a tooth can be messed up (and there’s always the option of extraction) and there’s only so many things that can be wrong with your eyes glasses-wise (near-sighted, far-sighted, astigmatism) so it’s easy to say “we need more patients” because an assembly line will, in fact, work. This kid needs a filling, that kid needs glasses for 20/40 vision, and these people will never have to deal with the crap that House has to deal with?

  2. I’m not exactly sure how retail clinic is defined here. In Carroll’s post, it sounds like a Walmart appendage sort of thing with an MLP. But a lot of what you describe sounds like the clinic I always went to back home. The entire notion of a doctor-patient relationship was alien to me until I met my wife (the Back Home Clinic then the University Clinic). It was just a big building, take a number, see whoever draws you. Kind of like Supercuts.

    But the person I visited was actually a doctor. When I was back home and got pneumonia, I got a chest x-ray (there was a blood test, too, though that they might have sent out for), so they have equipment, too, which I am guessing is less what you are talking about. I’m not sure how meticulous they were about patient records, though. It sure seems like we had to refill out all those forms every time I went.

    When I met Clancy and she told me what she wanted to do and talked about the doctor-patient relationship, and waiting days to see my doctor rather than hours to see any doctor, it all seemed like something of a foreign concept. It’s what I have been doing since, though I’ve never been in a single place to really strike up a real relationship with any single doc.

    • This applies mostly to clinics that function solely as retail outlets for medical care. Urgent care clinics that are part of a medical center are a bit less of a concern, though still not ideal. The bottom line is that you want to go somewhere where the providers know you, coordinate your care from both an acute and chronic perspective, and have your records.
      • Russ,
        We’re supposed to be getting a system where we all have access to everyone’s records. Oh, say by 2014 (ROFL). Right now, the urgicare places around me probably have better access to records than most doctor’s offices (NOT mine, I go to an outpatient doctor’s office kinda thingy at the hospital itself (run by teaching docs), and I’m pretty confident that they can pull whatever they please).

        THAT said, if you were my doc, I’d have gone to see you on Saturday. On Friday night, my husband needed a dental abscess lanced, for which we spent 5 hours in the emergency room, about three of which were spent with him steadily descending into mild shock (fingernails turning blue/shivvering) — 5 hours, and we got 10 minutes of care, that didn’t even include an antibiotic wash. Then we got to walk a mile and a half home (again, before any sort of treatment of that abscess other than by scalpel).

        It’s… at about that point that I wished I had actually gone to the urgent care facility. There, they -might- have had the time/attention to actually look a bit harder at the condition.

        • note: by the time my husband got home, he was at moderate shock/hypothermia (judgement severely impaired). And then he had some percoset… (ayiyi. this has been a bad week)
  3. The first time I encountered this “urgent care” concept was at the beginning of high school, when one opened (in the shopping center, of course) near my home. We went there initially for flu shots, because it was easier to drive five minutes for a shortish wait than twenty for a long one at our primary physician — but with the exception of physicals, this wound up being where we went for the remainder of high school. There were a handful of reasons: the much shorter drive, shorter wait times, the fact that we were kind of outgrowing a pediatrician (and certainly his waiting room) — but the most important was that we received the blessing of our pediatrician, who made some calls to get a sense of the medical reputations of the doctors working there.

    On the other hand, I’ve been to one in the current town, and it left me with the decided opinion that I need to establish ties with a primary-care physician up here. Soon. Before I get sick. I was more than willing to pay $10 for advice on backaches that came from someone or something other than the internet, but excepting that my insurance deductibles do slightly encourage my going to an urgent care center, it’s not somewhere I’d want to go again.

  4. I’m not sure just what kind of clinic Russell refers to. If it’s urgent-care clinics, such as J.L. Wall refers to, then I have to give them a thumbs-up, because several times they’ve kept me from clogging up an emergency room, and another time would have if I’d known where one was. In one case it was to treat a relatively serious asthma attack (for which I would have been justified in going to the emergency room, but it was still better that I didn’t have to), another time for a piece of glass in my foot (which I suppose could have waited ’til morning, but that’s hardly the type of thing where I need to know and trust the doctor), and the time I would have preferred one to an emergency room was when I split my head wide open running into an open door in a house we’d just moved into (medical attention definitely needed, but an emergency room was overkill).

    All of these things happened after 7 p.m. or on a weekend, when even a relatively accessible clinic like Dr. Saunders’ would not be open. So I’ll admit I’m a fan.

    But perhaps I misunderstand, and that’s not quite what he’s talking about when he says “minute clinics.”

    • For all of the medical events you describe, waiting for a visit with your primary provider would either have been inappropriate (asthma attack) or unnecessary (glass in foot, stitches). For problems along those lines, an urgent care provider is a good alternative to the ED. For problems that can wait, my recommendation will still be to see the primary provider.

      There are two broad categories of urgent care clinic that I can think of. The first is often affiliated with a hospital, and is seen as a good resource for problems such as the ones you describe that don’t need an actual ED visit. These are a decent option when urgent evaluation is really warranted. Obviously the quality varies depending on the quality of the affiliated hospital, and ideally you’d want to go to one where your own primary provider has privileges for the best chance of getting coordinated care.

      The other is a more recent phenomenon, wherein retail outlets have medical providers on site for acute illnesses. I am… deeply skeptical about the quality of the care provided, at least so far as I have been able to observe.

      • OK, I get your distinction. I was referring to the first sort (affiliated with local hospitals and/or medical group).

        The second is, I agree, worth being skeptical about. But–not that I actually know much about this–I’ve heard that Wal Mart is experimenting with having low-priced walk-in clinics. In a system where not everyone has health insurance, I’m not sure that’s a bad thing, even if we agree it’s not an ideal thing. From what I’ve heard (although it’s admittedly vague), they don’t assume they’re equipped to treat everything, but treat what they can and when they can’t treat, advise patients/customers on what the problem appears to be and what they ought to do as a next step. If-emphasis on if–that’s the model, I think it’s worth cautious support. Cautious support, of course, entails holding onto some skepticism.

          • Russell:

            Really, just bc someone gets care from a doc in the box doesn’t mean the care will be substandard. My wife a hospital admin saw substandard care from the docs in the internal med clinic she ran and it was part of a hospital.

          • Of course. Crappy doctors find their way into practice in all manner of reputable-seeming settings. One would hope better providers would find themselves in practices commensurate with their quality, but there’s no guarantee that even great medical centers don’t have quacks on staff.

            Conversely, I’m sure there are plenty of providers at “doc in a box” practices who deliver good care. I readily concede that there are likely to be exceptions to the generalities I sketch in my post.

            That said, for the reasons I enumerate and based upon my own observations of the care I’ve seen delivered, I recommend against them.

      • This may sound foolish, but can an adult be treated by a pediatrician?
        Let’s say you were my pediatrician, and I was so happy with your great care and treatment that I wanted to continue seeing you and only you. Just curious.
          • Hei,
            Never, ever ever bring an animal to a Children’s Hospital. Or to an adult hospital. Their first duty is to humans, and I wouldn’t want to see someone die because of an allergy attack (not a hypothetical!)
          • Kim, Oops. Never even thought of it from that angle. I could imagine the reaction of patients waiting in the ER, and seeing a dog rushed in on a stretcher for emergency care–it would cause a riot.

            I really never considered bringing one in, especially a Children’s Hospital, I was just curious if a hospital would intervene if a police dog or bomb sniffing dog was in mortal danger. As in removing a bullet or sewing up a knife wound.

            Riot averted! Thanks.

          • Hei,
            the equipment isn’t set up for a dog, they don’t have the proper restraints, etc. There are probably 24 hour emergency vets, and the cops probably have their number on speed dial.
  5. This is just more along the trend of treating medicine like any other business, where getting a wound treated is not really any different than buying a toaster.

    Of course the clinics work well for those gainfully employed with money. Everything does, doesn’t it?

    For those without, the long waits in ER are not an inconvenience, they can often be deadly. Its not unheard of for poor people to literally die on the floor of an ER waiting for treatment.

    But because people like us, (those who write posts on this blog) crowded ERs are something we heard about once, or experienced briefly as if in a visit to a 3rd World nation.

    Because the world of poor people in America is so distant, it scarcely rates a thought. Or more precisely, it scarcely rates a thought to the decision-makers who determine funding and policy.

    • But because people like us, (those who write posts on this blog) crowded ERs are something we heard about once, or experienced briefly as if in a visit to a 3rd World nation.

      Well then, it’s good that we have people like you to tell us how the real world is.

    • … as If I don’t live in a city… as if people in my office haven’t been ten hours at an emergency room.
      Okay, so I’m the bleedin’ liberal around here, but beg your pardon, I do understand.
      Experiencing mild hypothermia at an emergency room? Last weekend, thank you kindly.
    • Liberty,

      I lived in San Francisco, and for several years had no health insurance. I nearly died in the emergency ward of San Francisco general when I stopped breathing–entirely–from an asthma attack. The man in the bed next to me was a 37 year old heroin addict who was HIv positive (I saw his DOB on the bag holding his belongings) who I would have guessed to be in his early ’60s. My wife (then girlfriend) saw a guy come in with a big chunk of his face blown off, and watched the police wrestling a guy who was yelling, “My name is Snake! And I killed him; I killed him dead!” It only sounds like a line from a movie–it was real.

      Yes, crowded emergency wards can be deadly. As an asthma patient I was prioritized because I was more likely to die than even the guy missing part of his face, or the people with green snot streaming from their noses and gunk matted around their eyes. That’s why I like being able to go to an urgent care clinic instead of an emergency ward, and if a pure for-profit retail clinic had the appropriate equipment to treat me (which is actually pretty simple), I’d even go there before an emergency ward.

      So I’m not disagreeing with you about the problems of emergency rooms. But for god’s sake don’t make so many damned assumptions about people who’s life histories you don’t know!

      • … Jesus that sounds bad.
        Knew a guy (22 and fit as can be) fell over after heading up Cardiac Hill — turns out the air here can knock you dead (to be fair, he is allergic to sulphur, and it was a bad air quality day).
        Got took to the ER — then escaped when he woke up (to be fair, he had a “do not treat” order).
      • I stand corrected.

        It seems that people here are more familiar with inner city ER conditions more than I assumed.

        So when we do have a discussion about how best to provide health care for poor people we can talk from a common frame of reference.

        • Cancel Christmas. (only half sarcastic today…)
          You’ll need to clarify the question a bit more — are we talking about providing decent emergency room stuff, or wellness in general?
          • “That’s a noise,” grinned the Grinch,
            “That I simply must hear!”
            So he paused. And the Grinch put a hand to his ear.
            And he did hear a sound rising over the snow.
            It started in low. Then it started to grow…

            But the sound wasn’t sad!
            Why, this sound sounded merry!
            It couldn’t be so!
            But it WAS merry! VERY!

            He stared down at Who-ville!
            The Grinch popped his eyes!
            Then he shook!
            What he saw was a shocking surprise!

            Every Who down in Who-ville, the tall and the small,
            Was singing! Without any presents at all!
            He HADN’T stopped Christmas from coming!
            IT CAME!
            Somehow or other, it came just the same!

  6. I overall agree with this. I’ve never had to wait for an appointment that really needed same-day attention. If I’ve ever had to wait, it’s for something that seemed like it could wait. But I do live in a non-depressed area of the country.

    I think asking people to miss school, etc., is totally reasonable most of the time. But there are a couple of things I’d like to say. I have a kid with serious health issues. I average about .75 doctor appointments a week. I often have little choice about when and what day I can bring him in. If I did not have a job with flexible scheduling and a VERY understanding department, I literally would have to quit my job just so I could take him to doctor appointments. I know other parents whose kids have my son’s syndrome who did quit their jobs because of this. My closest special needs mom friend was once a lawyer – now she can’t be. Not that urgent care would address this issue, but just to bring up that medical scheduling can be serious.

    Another related issue is waiting. Most doctors inform you that if you are >15 minutes late to an appointment, your appointment will be canceled. Yet when I come, I am often forced to wait 1-2 hours. Like over 2/3 of the time. Especially when you have a kid (especially a special needs kid), this is a major pain in the ass. No one calls me and tells me to come in the office a little later. This is more common with subspecialists than with primary care, but it still happens with primary care. I note with interest the asymmetry in respect for time – they expect us to have respect for their time, but they have little respect for ours.

    Some respect for parents’ scheduling needs when making appointments (instead of “the only time the doctor has is time t, and if that doesn’t work for you, well, I guess you’re screwed”), as well as respect for seeing people when they actually show up would probably mitigate some patient frustration.

    • I certainly understand that medical scheduling can be a significant hardship in the context of chronic and/or severe medical conditions. Sadly, I don’t know of a good solution to this problem.

      Aside from our walk-in hours (where part of the bargain is understanding that anyone can come, and if it’s really, really busy [like it invariably is this season] then you have to wait indefinitely), I rarely have patients waiting for more than 20-30 minutes (usually much less) and am profusely apologetic for waits even that long. It is inconceivable to me to ask patients to wait 1-2 hours… ever. I can’t help but agree that physicians have an obligation to be as respectful of their patients’ time as they expect for their own.

      • *snerk* i had a “it took me two hours” to get in and out of a 15 minute annual this year. Granted, that was because they were letting a med student get some practice diagnosises in (I didn’t mind too much… but if I had wanted to get back to work, I would have).
      • Yeah, I’m not sure what the solution is, either. But the wall between the ability to reach a doc on the phone (which I understand the need for) and the scheduling situation do create something of a disanalogy with, say, plumbers. I wish it was something to which more docs attended. Glad you do!
    • That’s a side-effect of certain clinics needing (financially) to keep their doctors scheduled completely full, four patients an hour or more, all day, in order to break even. Which means that ANYONE’s delay can cause train-wrecks with the entire rest of the schedule for the day.

      It sounds like Our Kind Host works somewhere that doesn’t do that, and that’s lovely (both for the doctors and for the patients), but chronically-overscheduled clinics are a fact of life in the American healthcare system.

      The way insurance reimburses means that it is financially risky for many practices to schedule more than 5-10min per patient, per doctor, all day. I spent over ten years in a series of practices where the doctor literally had to make other patients wait if he/she wanted to talk to me long enough to really get an idea what was going on with me — the intended method of service was “:nurse comes in and asks a few questions, checks vitals, makes sure I’m ready and waiting / doctor pops in and sits down, glances over what the nurse wrote, asks me 1-2 quick questions, makes a decision on method of treatment / nurse comes back in to administer shot, if desired /secretary writes me a scrip when I go to the end to pay.”

      It took me two years and a load of runaround to get an endometriosis diagnosis out of one of those practices, because they insisted on testing me for every STD known to man at least twice and then putting me on increasingly-huge pain pills when they “couldn’t find any reason” why I should be in pain. It took my mother showing up and threatening lawsuits in the secretaries’ faces to get them to even consider the fact that I’d told them repeatedly I had a family history of endometriosis, ovarian cysts, and other reproductive abormalities might be relevant, and schedule me an ultrasound.

      This practice was associated with a major university with a medical program that has a good reputation.

  7. “One of my recurring bugbears is the steadily-blurring line between patients and customers. ”

    One shudders to imagine how bear-bitten you’ll be when you one day awaken to the truth that people principally think of themselves as people, and as patients only when they cannot avoid doing so. It’s fairly clear from the following passage that you have gone about your professional practice presuming to the contrary:

    “The expectation for customers at the end of a transaction is that they be satisfied, and everyone knows the axiom about them always being right. A patient, on the other hand, is supposed to be treated.”

    We’ll ignore the companionably presumptious twaddle you appended to these 2 sentences…..

    allow us to paraphrase:

    ‘The patient, on the other hand, is an object on which a clinician acts.’

    In this light your confusion about retail clinics is much easier to understand.

    “The first and most obvious reason to avoid them is that they have no access to a patient’s medical record, and thus their medical history. ”

    YOU have SOME access to your patients’ medical records, but it will probably horrify you to realize it’s probable that you only have a fraction of their relevant medical record on hand at any time.

    Happily, none of your sentient patients is likely to imagine otherwise.

    Meanwhile, do your homework: as much as 60% of retail clinic clientele assert they have no primary care physician (….only 39 percent of the retail clinic population reported having a usual source of care, compared with more than 80 percent of the United States population (“Retail Clinics, Primary Care Physicians, And Emergency Departments: A Comparison Of Patients’ Visits”, Mehrotra et al., 2008)

    For many in that 60%, this situation is not a bug, but a FEATURE; that is, they are not particularly interested in HAVING a primary care physician.

    “They don’t know what medication allergies a patient has, what medications they’re taking, and what medications may have been tried already for any particular complaint. ”

    Ask most of the pharmacists who fill your patients’ prescriptions how much faith anyone should put in YOUR grasp of the array of medications your patients are taking, and their interactions. You may be the exception to their (and the general public’s) dim view, but that remains to be put to the test.

    “…I’ve observed that the care delivered at these clinics is sub-par. ”

    And I’ve observed that the sun rises in the east, so probably the sun orbits the earth.

    “…far more often than not the patients who return to my office for follow-up care after having visited one of them have been put on medications they didn’t need (typically antibiotics) for infections they didn’t have.”

    Again, your anecdotal observations don’t square with the readily-available evidence. From “Policy Implications of the Use of Retail Clinics”, a 2010 Rand Health compendium of research on retail clinics care:

    “Three studies have examined rates of repeat visits and of follow-up care received at other sites after an initial provider visit. The first, Mehrotra et al. (2009), found similar rates of follow-up visits for related conditions for patients with otitis media, pharyngitis, and urinary tract infections after being seen at retail clinics, physician offices, urgent care centers, and emergency departments The second, Thygeson et al(2008), found a 2-percent higher rate of return visits for episodes of care initiated at a retail clinic compared with those initiated at a physician office or urgent care center. These two studies used similar datasets with an overlapping set of diagnoses. The reasons for the differences in their findings are unclear but may be attributable to different study methodologies. The third study, Rohrer, Angstman, and Furst (2009) and Rohrer et al. (2008), examined rates of return visits within two weeks for adult and pediatric patients seen at retail clinics. Rates of return were not statistically different for patients seen at retail clinics compared with those seen for a same-day acute care visit at a physician office.”

    “Why do these clinics seem to hand out these medications like they were candy? ”

    Ah, but AGAIN there’s the little matter of the fact that they don’t. The evidence, doctor:

    “…a study that examined rates of antibiotic prescribing did not find any evidence to support this concern, noting that antibiotic prescribing for sore throats and middle-ear infections at retail clinics was similar to rates at physician offices: 25 percent of patients with sore throats 30 received antibiotics at retail clinics compared with 29 percent at physician offices (Comparing Costs and Quality of Care at Retail Clinics with That of Other Medical Settings for 3 Common IllnessesMehrotra et al., Annals of Internal Medicne, 2009).

    “While I have no doubt that providers there have some standard of care their seek to meet, I question whether the context of their patient interactions makes best practices possible.”

    Of course it does. In fact it makes systematic, rational practice MORE likely there than in YOUR practice. (“best practice” has long since become the “all natural” of business buzzword bullshit, doc – please try to keep up).

    It’s well-documented that physician treatment protocols, and the results of care, vary considerably from region to region across the country, for no discernible clinical reason. It is, apparently, just doctors choose to do things – science, evidence, effective patient care be damned.

    “Some patients will be unhappy with being told they’re not getting a medication, and letting them leave dissatisfied is inconsistent with the mission of a retail clinic.”

    Ok, have we gone far enough with this? The evidence is overwhelming: you haven’t bothered to do your homework, but you HAVE decided you’re welcome to your fact-free opinion. We get it. So now we can safely ignore it.

    “The dynamic is different for patients at a primary care office. The relationship, at least ideally, is one of mutual respect and trust….There is nothing analogous in the setting of a minute clinic.”

    Oh, but there’s plenty “analogous”. One small example: do YOU thoughtfully prepare a written summary of a patient’s visit, and offer to transmit it both to him/her and to another of his/her clinicians?

    We didn’t think so…..but retail clinics routinely do.

    “…Why would seeing the provider who is most likely to deliver better care a consideration that takes a backseat to convenience?”

    Possibly because the nature of the care that’s needed doesn’t require appearing at your at your location, at your whim. People are people first, and patients later, if ever.

    Next time you’re looking for things that need fixing about the way health care “works” here in the US, start by looking in the mirror, Dr. Saunders.

    • My first response to your comment is to note that the various interesting and valid points you make are marred by the flagrantly confrontational tone you have chosen to adopt. It does rather raise the question of whether responding further is a fool’s errand, and only likely to generate a similarly distasteful reply. I’ve managed to have many fruitful conversations with interlocutors whose opinions differed from mine, and endeavor to create a civil tone hereabouts. I’ll make one attempt to address the points you raise, but if you insist in being persistently obnoxious then I’ll simply start ignoring anything further you have to say.

      Your inference that I do not view patients as sentient humans is unfortunate. That I do not always think they are right does not mean I do not think them capable of making good decisions for themselves, or that they must always do what I say. However, as I’ve discussed often enough on this blog, patients often want things I do not believe are medically indicated or appropriate, as just about any physician anywhere would probably also tell you. Stating this plainly is nothing like saying they are objects upon which I act, a preposterous bit of overstatement if ever I saw one.

      Yes, there are many cases where the record I have available is incomplete. How this is a good argument for seeking care in a place where the records are even more scanty or nonexistent escapes me. The same point holds for your implication that my grasp of everything my patients are taking is imperfect — it may well be, but that hardly means going somewhere where the provider knows even less is better.

      I’m not going to rhapsodize about the benefits of having a primary care provider. If patients don’t want them (let’s just go with the veracity of your statement for now), then fine. I happen to think that’s going to result in sub-optimal care over the long term, but that’s just me.

      I have no earthly idea what your comment about the sun is meant to communicate.

      Since I don’t have access to that Rand report you cite, I can’t really comment with any authority. All I can really say is that rate of repeat visits seems an odd way of measuring quality of care. As to the one study you reference about the rates of antibiotic prescriptions, perhaps my impression is wrong. It is based upon my own consistent observation, which is obviously not omniscient. It does, however, remain my impression.

      Sifting through the nastiness sprinkled liberally through your remaining comments, you seem to be saying that systematic, rational practice is more likely in a retail clinic because (and I’m inferring a bit here, since your didactic structure seems to fall apart a little) retail outlets set consistent protocols for all of their outpatient clinics, and it varies from provider to provider in the primary care setting? If this is truly the case, I’d find that interesting. Finding a good balance between evidence-based medicine and cookbook medical protocols is always a challenge, and I’d be curious to know how a retail outlet did it. Since I’m genuinely curious, please feel free to give me more information in your reply. Just do make an effort to be civil, please.

      Do I provide a written summary of every patient visit? No, and I suppose that’s a nice thing. Since I’ve seen many a written summary of truly, astoundingly shitty care delivered by many local outlets (in fairness, many of which have been emergency departments rather than minute clinics), a written summary is only as good as the care it summarizes. I do all kinds of other very nice things for my patients, which they seem to like just fine.

      And again, you conclude your comment with absurd hyperbole. I don’t tell patients where to appear at my whim, and your line about patients being people first merely reminds me of an old Depeche Mode song. I’ve already gone to the trouble of saying why I think being seen in a primary care office is better in the original post, so there’s no point in repeating it now.

      Anyhoodle, there’s my response. I’d hate to think your inability to compose a pleasant reply would keep you from answering some of the questions I’ve asked with sincerity. If, however, you really can’t write pleasantly, please do me the favor of not writing at all.

  8. Facts aren’t confrontational, Dr. Saunders; facts are facts. That they ‘injure’ you says more about the thickness of your skin, or more pertinently the thinness of your rejoinders, than the assertiveness of my tone in “confronting” you with them.

    “Your inference that I do not view patients as sentient humans is unfortunate.”

    I inferred rather that none of your sentient patients imagines you hold in your possession a picture of their health that, in contents or form, contributes a great deal to their flourishing. I made and make no judgment about your view of your patients, other than that it seems tinged with condescension.

    “Yes, there are many cases where the record I have available is incomplete. How this is a good argument for seeking care in a place where the records are even more scanty or n
    nonexistent escapes me.”

    You’re guessing again, because you have made no systematic comparison of what your record holds that a retail clinic’s might not. Happily for you, I suppose, a useful evaluation of that kind is unlikely to be undertaken by any of your patients.

    ” The same point holds for your implication that my grasp of everything my patients are taking is imperfect — it may well be, but that hardly means going somewhere where the provider knows even less is better.”

    It does mean, however, that doing so may well be no worse.

    “I have no earthly idea what your comment about the sun is meant to communicate.”

    You asserted that you had “observed” that retail clinic care is sub-par. I in turn “observed” that the sun appears to rise in the east, my point being that my observation is about as useful, as descriptive of the way things actually are, as yours.

    “Since I don’t have access to that Rand report you cite, I can’t really comment with any authority. All I can really say is that rate of repeat visits seems an odd way of measuring quality of care.”

    The pertinent observation had to do with follow-up visits. You insinuated that you’ve been inundated by patients seeking remedial care for their maltreatment at retail clinics. My reference to the research on the subject indicates that retail clinic patients seek follow-up treatment at rates quite like those seen among physicians’ patients for like conditions, presumably with similarly salutary results. If care weren’t of like “quality”, surely the evidence would show retail clinic follow-up visits were of greater frequency, and the record of remedial treatment clearly condemnatory of the preceding retail care?

    “As to the one study you reference about the rates of antibiotic prescriptions, perhaps my impression is wrong. It is based upon my own consistent observation, which is obviously not omniscient. It does, however, remain my impression.”

    Ever the man of science….

    “…you seem to be saying that systematic, rational practice is more likely in a retail clinic because…retail outlets set consistent protocols for all of their outpatient clinics, and it varies from provider to provider in the primary care setting? If this is truly the case, I’d find that interesting. ”

    Perhaps now we’re getting somewhere.

    “Finding a good balance between evidence-based medicine and cookbook medical protocols is always a challenge, and I’d be curious to know how a retail outlet did it. Since I’m genuinely curious, please feel free to give me more information in your reply.”

    They do it, generally, by selecting protocols (no clinics I’m aware of invent their own; rather, they seek models adjudged the best by clinical experts, and adapt them for their narrow purposes) and then measuring their clinicians’ adherence to them. Unlike you, or most US physicians, most retail clinics can at least produce a verifiable record of their practice activities. Their capacity to do so is built into the way they go about their practice.

    You ought to devote more effort to keeping up with your CE obligations; this sort of elementary information about retail clinics has been available for years.

    “your line about patients being people first merely reminds me of an old Depeche Mode song. ”

    Oh, for heaven’s sake, if you’re going to quote, get it right – PEOPLE are people first, and patients incidentally. Any of your honest patients would tell you, straight out, that you are incidental – at best – to their lives, and an inconvenient and unwelcome incident in many cases, and would be have no role in their lives at all if the world conformed to their wishes. This is not an indictment of you as a person OR as a physician; it’s a pragmatic summary of how people generally feel about obtaining health care. For most, it’s something to be avoided, postponed, diminished, endured. And for a few, something to be simplified, systematized, rationalized, improved.

    Get over yourself as the center of your patients’ health care world – you’ll find you’re a better physician for it.

  9. Pingback: Retail clinics make their pitch | National Latino Alliance in HIT

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