• And now I’m forced to like retail clinics a little

    One of the things I like most about blogging is that it constantly forces me to question my assumptions. Writing so much, and reading so much, requires that I continuously go back and reassess what I think. There have been times, many of them in fact, when I have changed my mind or readjusted my biases.

    So let’s talk about retail clinics. As a pediatrician, I’m supposed to hate them. You see, it’s hard to get into the whole medical home thing, and still tolerate their existence. We spend so much time in medicine talking about the doctor-patient relationship, stressing the continuity of care, that the idea of someone coming along and treating patients on the fly without any actual knowledge of them is somewhat repellent.

    Not only that, but so much of what people, on both sides of the aisle, talk about to improve quality includes things like coordinated care, improved health records, better communication between specialists and primary care, etc. Almost none of these things are what retail clinics focus on. So I’ve always been a bit skeptical of how they should be promoted.

    And then on Friday, my oldest child started complaining of a sore throat. My middle child also had been, but the positive predictive value of his complaints is notoriously low. I was instantly panicked. This was my first day back at work after vacation. I knew my wife was busy. How were we going to squeeze in two doctor’s visits into the middle of the day? Who was going to wait until the office opened to call and schedule them? I knew what the office was like. It would take hours.

    There went the entire day.

    But no! My wife said she’d just take them to the Minute Clinic to get swabbed on the way to school. They open at 8 AM. No appointments. It would take a few minutes and everyone would be on their way. Problem solved.

    Huh? What happened to the medical home? What happened to continuity of care? What about the doctor-patient relationship?

    It’s time to own up to the real world. It’s a sore throat. If it’s a virus, there’s really nothing to do but wait. If it’s strep throat, you want to treat it (to prevent long-term problems). But strep throat is one of the easiest things in the world to treat (Penicillin still works great!). There’s a simple and almost instantaneous test for it. And, get this, physicians are incredibly bad at diagnosing it clinically. A study found that a doctor’s guess as to whether pharyngitis is bacterial or viral is right about 50% percent of the time – no better than flipping a coin.

    So this is one of those situations when, really, a mid-level practitioner is more than enough to swab the throat, make the call, and treat the disease. Plus, the minute clinic is in the pharmacy, so you can even get the antibiotics right then and there. Finally, as Austin noted last week, care at such clinics costs significantly less than a doctor’s visit and WAY less than a trip to the ED.

    I’m sold. For strep throat, which accounted for 15 million patient visits in 2006 alone, retail clinics seem like a pretty good idea. While I still believe in the medical home and the importance of the doctor-patient relationship and continuity of care, I’m sure there are more examples of where they work as well.

    That said, there are lots of examples where they won’t. Don’t take this as an excuse to go overboard.

    AEC

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    • I think these could really be an asset to the health care system, if the retail clinic implemented a way to get their results into an EMR. You doctor could be alerted about your simple, common problems to discuss things that might be a frequent occurrence, or long-term healthcare problems, while the actual visits and tests would be much cheaper.

    • There certainly is a role for Retail Clinics and a growing (yet slightly biased) evidence base to support them. You can learn more by downloading our fact sheet: http://www.policyprescriptions.org/?page_id=1912

      My wife and I, both ER doctors, make use of our nearby urgent care centers for minor illnesses too.

    • John Goodman must have a smug smile on right now.

    • I’m 43 and I’ve never seen the doctor-patient relationship. Never. I’ve tried several different primary care physicians in my area, for multiple years and not one of them ever seemed to know who I was. Their offices do not send any kind of reminders. They do not follow up on visits either, i.e. there’s no call to see how things are going or if you’re feeling better.

      I’ve come to believe this is just how things are in the medical profession now. Maybe it’s incorrect. Maybe there are doctors who actually do seem to know you. I will even conceded that maybe it’s just me, maybe they have very close relationships with other patients. All I know is that my Dad, in his late 60s will still routinely visit his old doctor who is 8 hours away, if he happens to be in the area, because they are old friends and became friends simply because of that doctor patient relationship.

      I will admit that this isn’t necessarily true of pediatricians. My kids docs do seem to remember them pretty well.

      • Tim,

        I don’t know what part of the country you’re in, but I live in DC and have a great relationship with my doc. He’s part of a network called Privia. http://www.priviahealth.com

        If you check out their site, you can see if there’s a doc in your area that is in the network. I use retail clinics on rare occasions as well, but I feel like most of the points made in the discussion of doctor and patient relationships are addressed by the privia system. Lots of follow up and support after I leave the office. Lots of tools that are useful. Anyhow, food for thought. And yes, generally, I believe retail clinics have their place in this world as well.

    • Retail clinics indeed have a role. And they force traditional providers to actually deliver on the continuity of care/medical home/relationship dimensions of standard care.

    • Picking a nit, but docs are actually fairly good at clinically distinguishing strep from viral pharyngitis. The link you provided was for all forms of URI. But if you use the Centor criteria (developed by academic medblogger Bob Centor) the sensitivity is actually excellent:

      http://www.mdcalc.com/modified-centor-score-for-strep-pharyngitis

      http://www.medrants.com/

      However, none of this changes the fact that we probably shouldn’t be treating strep with antibiotics anyway:

      http://www.epmonthly.com/columns/in-my-opinion/antibiotics-for-strep-do-more-harm-than-good/

      Cheers,

      lty

      • What? If I’m reading that paper correctly, the percentage of cultures which were positive only broke 50% in those with the highest scores. And even then, just above 60%.

        http://jama.ama-assn.org/content/291/13/1587/T1.expansion.html

        My point it, you HAVE to get the rapid test. Even the “clinical scores” are only predictive half the time. Although, I do agree, that we way over-treat strep. But, for the sake of my marriage, I’ve learned not to argue too hard with my PNP wife when it comes to our kids.

    • -The list of things that PCP’s normally do that can and should be done at a drop-in clinic staffed by mid-level providers is quite large.

      When I want a PCP’s expertise for something like a routine checkup, give me the option to electronically submit my labs, physical exam notes from the drop-in clinic, and a brief summary of how I’m feeling to a PCP for a flat $50 fee (with the option to follow up in person if desired/necessary) and costs go down, throughput goes up, and I’d venture that satisfaction on both ends of the transaction increases while quality stays constant.

    • My Pediatricians Practice has a sick call from 8-9 Monday – Saturday, which helps greatly with things like this. They generally staff sick call with CRNPs, but the doctors in the practice are also there. I find that it provides the convenience of the retail clinic (no appointment necessary!) with the value of the continuity of care (all my kid’s medical records are at the practice).

    • They’re a fabulous idea and I don’t understand why the one in our town (Eugene, Oregon) is under utilized. http://allaboutoregon.blogspot.com/2011/10/future-of-health-care-delivery.html It seems the parent organization is ambivalent about its own clinic.