Monday, June 25, 2007

Misplaced Priorities

"There is no more urgent issue than this for the AMA".

What could it be?

Childhood nutrition and vaccinations?

Reducing obesity in society?

Making immediate treatment of stroke accessible to all?

Improving reimbursement rates for primary care doctors, psychiatrists, and other cognitive specialties?

Working to reduce medical errors?

No. Here's the context, from the Chicago Tribune story, AMA takes on retail clinics -- Doctors groups say patients in danger:

"The American Medical Association should call for a ban on in-store clinics being opened by retail giants like Wal-Mart Stores Inc. and Walgreen Co., several doctors groups urged at the AMA's annual meeting in Chicago on Sunday."

"Faced with an onslaught of competition that is forecast to bring several thousand retail health clinics to U.S. consumers, AMA members testified that such clinics are endangering patient care, particularly for children. The doctors say the clinics, largely staffed by advanced-degree nurses and physicians' assistants, are largely unregulated and, therefore, put patients' health at risk."

" 'There is no more urgent issue than this for the AMA,' Dr. Kamran Hashemi, a family physician from South Barrington, said, urging the organization to push for more regulation of retail clinics. 'This issue speaks to what all of us do every day in practice.' If the AMA does nothing, Hashemi said, 'in five years, the chairs [at the AMA] meeting will be filled with representatives from Walgreens, Wal-Mart' and other retail outlets."

I can't tell you how reassured I am to learn that our physician groups in Massachusetts are not out of the mainstream . . . .


Anonymous said...

There they (the AMA) go again. The key appeal of retail clinics is timely access including during the evening and on weekends. Cost is not as much of a factor, in my opinion. I think the AMA could serve its members much better by encouraging them to organize into larger groups so they could more easily provide evening and weekend coverage while also offering the patient a "medical home" and, perhaps, electronic records. Why is the AMA's first instinct always to try to eliminate competition rather than meet it?

Anonymous said...

More docs also should keep some same-day appts open. They send you to the ER instead. Even with ins, that is expensive out of pocket and here, the waits are upwards of six hours. We often use urgent care--though even that is a high copay. It is my understanding that both the ERs and urgent cares reply on insured patients' payments as a revenue stream--so they should quit bitching about people who go to the ER instead of their doctor. The doctor sent us! As for electronic records, that would be nice--then the doc would know what happened to the desperate patient they sent to the ER--now they don't even call and ask.

Anonymous said...

As I see it there are 2 issues here - competition and competence. On the competition issue, I am with all of the people who are for these clinics and against the docs, and I agree with all the comments about it unloading PCP's and ER's etc.

However, on the competence issue, I as a physician do have some concerns, and I think the concern for a sick child is valid. Kids can have very severe illnesses such as meningitis which present in weird ways and can progress to life-threatening in hours. I think it would be easy for a storefront clinic to underestimate such a situation and perhaps lull a parent into a lack of vigilance which could prove fatal. Even ER's sometimes miss these things; that's one reason many hospitals have established specific pediatric ER's.

As I mentioned in Paul's very first post on this issue, we shall see what happens to these clinics when they have their first (justified) lawsuit. I, for one, would rather rely on my experienced pediatrician if I had small children anymore.

Anonymous said...

Anon 8:09,

That's a good point about the sick children. An executive at Walgreens, who has young children himself, told me that his pediatrician reserves the first hour of each business day for families with sick children to show up without an appointment during that time so the child can be seen by the doc quickly if he or she got sick during the night. Since it is even more important for a child to have a medical home than it is for an adult, pediatric practices should probably do more to insure that sick children can be seen by a doctor on a timely basis.

Anonymous said...

Sorry, but I don't buy the argument about misdiagnosis of children's ailments as being an excuse not to have these clinics.

Which is more likely to lead to a worse result: Having no ability for a child to be seen because a doctor's office is closed, or going to the mini-clinic and seeing a nurse?

Which is more likely to lead to an incorrect diagnosis: Getting an over-the-phone opinion from the on-call pediatrician during off-hours, or going to the mini-clinic in person and seeing a nurse?

Of course, anyone would like their child to be SEEN by a pediatrician, but that is not always what takes place. Children have an odd habit of getting symptoms during off-hours.

Meanwhile, do we really want all these bee stings, tick bites, and other minor childhood problems to be seen in the emergency rooms?

constance_liu said...

I've been following this discussion about retail clinics with some interest. I'm writing a case study of the main public hospital (Metrohealth) here in Cleveland - they've been expanding their services by way of community health centers that are deliberately placed in retail centers. The model worked out pretty well - patients have better geographic access to care, Metro has better visibility in the community, and the convenience and quality of care draws a commercial in addition to the traditional uninsured/Medicaid patient population that Metro serves.

My reaction is this: I think that placing clinics in retail centers is a natural fit. These stores are placed to be as accessible as possible to people - and having more access points that allow people better preventive care will, in the end, benefit everyone involved.

Toni Brayer, MD said...

You are right on with this post, Paul. The marketplace is responding to the need for access, convenience and affordability. If we doctors provided it, these clinics wouldn't be cropping up all over. And the AMA sees this as an urgent crisis? What about the fact that the U.S. has no policy for basic healthcare for millions of working folks or the fact that primary care is headed for the dinosaur tarpits? It's easier for organized medicine to get in an uproar about competition than to really take a stand on reform.

Anonymous said...


I'm anon 8:09. It seems you have misinterpreted my comment, and I detect a little impatience with my objection, perhaps because I said I was a physician? (That's all right, the prickly relationship between CEO's and docs is universal, and I love your blog.)

Your first sentence;
"Sorry, but I don't buy the argument about misdiagnosis of children's ailments as being an excuse not to have these clinics."
puts words in my comment that weren't there ("not to have these clinics"). You also ignored my first paragraph indicating that I, like you, dismiss the AMA's and other's arguments. I actually favor trying these clinics and seeing how they work, with fine tuning down the road based on experience. (Arguments and theories ahead of time are great on both sides, but only experience will tell the tale.)

Also, yes I would, and did, definitely call my pediatrician during the off hours and get her opinion, and I would consistently do that rather than go to a mini-clinic and see a nurse, you bet your bottom dollar. Pediatricians receive thousands of these nighttime calls, know their patients, and can usually tell over the phone what is wrong. If there is doubt, they refer you to the ER, properly. If one does not have a pediatrician, that is a different story, but that leads into the whole different discussion about disparities in access to medical care.

There is an easy way to mitigate at least some of the pediatric problem - the clinics should not treat any little kid with a fever over, say, 101F (I am guessing; this is not my specialty), and refer them to either the local ER or a clinic with pediatricians. I also notice the article says they will not treat under 18 mos, and some are saying it should be raised to 3.

But I just had a thought; has anyone said what the hours of these storefront clinics are going to be? Maybe they couldn't see a kid in the middle of the night anyway.

Anonymous said...

Sorry, anon 8:09, for giving the impression that you said things you did not. I think I was responding more to calls and emails I have been getting, especially from pediatricians, which were not nearly so tempered as your thoughts. Apologies for giving your thoughts short shrift.

Chasing Inspriation said...

I live in a state where MinuteClincs are a growing phenomenon and where employers encourage employees to go to MinuteClinics in response to ever climbing medical insurance costs.

I see a physicians assistant at my primary care clinic. I trust her judgement and would not hesitate to see a PA at a MinuteClinic for those non-critical ailments that can befall a person. MinuteClinics are convenient, offer me the same services (without the wait) as Urgent Care for most of the ailments I would go to Urgent Care for, and yet cost much less out of my pocket.

I grew up in Canada, and yes we have our problems and issues around our medical system, but I grow more and more appalled at how health care costs are skyrocketing in this country and how the community who can't afford health care is growing and expanding from those living in poverty to the working poor and pushing into the middle class. Something needs to be done. I don't know if MinuteClinics nad the like are the answer. I think the solutions requre an overhaul of the health insurance and other industries. But if the Minute Clinic model provides affordable and timely basic care why should anyone fight it?

Anonymous said...


No problem with the misunderstanding; I bet your door is being beat down. I think we have to be careful not to throw the baby out with the bathwater, though. Although the motives behind the objections may be questionable, the objections themselves (as in peds) may have some merit. I think liability fears on the part of the clinic owners and the nurse pracititoners will probably solve this problem by itself, at least initially.

BTW, nurse practitioners do not like to be called "nurses". They do have more training and are, in my mind, entitled to be addressed as NP's rather than nurses.

Anonymous said...

I read this statement by the AMA as a stop gap, as they work towards adapting along with the marketplace. A reactionary statement as such leads me to think that the AMA recognizes that the shift towards 'retail' healthcare is inevitable, and that means a large amount of their business will be changing markets. I don't think it's a stretch to read a little bit of 'intimidation' from this statement either, when you consider the issue of staffing these clinics. All in all, I think that in using this kind of language, drawing those parallels, and bringing up 'the children', the AMA is conceding that these clinics are in a very difficult position to attack logistically. They serve the purpose of resolving minor healthcare issues, and at least on paper, they serve it very well. Irrational arguments such as the AMA's only further this point.

Anonymous said...

Anon 8:09 !!

In response to your statement

"NP's do not like to be called nurses...they want more credit than that.. ect"

What credit are you talking about? The credit that only a white jacket can evoke? The type of credit that can only be given to a nurse who looks like a doctor because she finally gets to where a white coat because she has an NP after her name?

I am assuming that the genesis of your comment was to reflect the "higher status" of a nurse practitioner. While your statement met that happened to offend nursing as a profession.

To make a statement that a "regular" nurse doesn't embody a slot in the healthcare system that demands credit or respect is NOT acceptable. Our healthcare system needs as many resources from as many disciplines as possible. The issue of the in store clinic reflects this point.

The AMA's defensive and strong opposition to these clinics has to do with the fear of a loss of power.

A healthy and integrated response from the AMA would have been one of collaboration and support for our greater good. They slammed the door shut on the idea without even trying to develop it into a healthy place. If medicine continues to function in this pattern it will turn inward on itself in a destructive ways. We have already seen this.

Great solutions lie outside of the box with as many perspectives as possible looking at the problem.
Paul does this all the time at Beth Israel and that is why it is such a great place to work. I have been present when he speaks with our janitors to ask how he can make Beth Israel better. This principle must be embodied if you are to build any strong system...our nation's healthcare system included.

From what I can see medicine is doing all it can to keep the box closed with no outside collaboration.

This will not work forever..

Other disciplines will have to find creative ways to meet our countries needs....nurses are preparing for those times. Maybe then maybe they will get the credit they deserve.

Anon 8:09
You should read Paul's blog from back in December (Heart Attack Grill). The discussion reflects issues with dysfunctional societal views of nursing. Maybe this post will help you to be a bit more informed. I am sure your colleagues (that is the nurses you work with ) will appreciate it.

-Just an RN

Anonymous said...

Anon 10:07:

Whew, I guess I got told! Sorry, no offense intended. I merely made the observation that NP's have taken extra training in order to be qualified to work more independently than an RN, so they deserve to be addressed as an NP rather than an RN. It's like having a master's degree vs. a PhD, no? I did not mean to say that RN's have no intrinsic worth.

It's interesting; there is a repeated strong undercurrent of resentment of physicians in these comments and in a lot of healthcare blogs I read; and yet when I read posts in Sermo (the physicians' only website), there is a strong undercurrent of discouragement and even despair with the profession they have chosen. No one is happy on any side. It is no wonder the patients(and I have been one of those too)feel caught in the middle of this low-morale morass of different health care providers. With no trusted leadership being provided by either the AMA, feds, insurance companies, or any other players except maybe some states (tentatively and incompletely), I fear for the health of us all.

Anonymous said...

To RN 10:07 and Anon 8:09,

I detected no intention to show disrepect to nurses. I think you are "vigorously agreeing" about the skill and attributes and caring and judgment they bring to the profession!

Also, see my Wednesday posting this week to the student about other types of work and workers in the hospital setting. Marvelous people in a very, very tough setting.

Anon 8:09,

Regarding your last point, I have noticed the same and have been trying to formulate some comments on that topic. Stay tuned.

Labor Nurse, CNM said...

I second what Dr. Brayer said. Exactly.

In regards to the NP vs. RN an RN who is going to be advanced practice next year I certainly didn't take those comments offensively. Even with NP and CNM credentials after my name, I am still a nurse, and proud of it. Call me a nurse any day!

Also, I would imagine that these retail clinics will heavily refer out on cases they know they can't (and shouldn't) handle. They will likely have protocols that they follow, some of them even including sending people to ER's if they suspect even the slightest of major problems.
I have to say from my experience as an advanced practice nurse student that my course in primary care was heavily laden with what our boundaries are and that referrals and collaboration are our best friends. Perhaps there are a few cowboys and girls out there, but I believe that most NP's and PA's know their scope of practice very well.

ps. paul, I have a new blog.