Thursday, January 10, 2008

Will MinuteClinics be a Wash?

We have blogged several times, (most recently here, here, and here) about one of the latest health care fads, in-store clinics. Such clinics are situated in retail stores, such as drug stores, staffed by nurse practitioners, but usually not doctors, and claim to treat a limited number of ailments quickly for reasonable prices. They have been touted as the latest business-like solution to the decline of primary care.

A lot of people have objections to this concept. My concerns center around how the clinics will be able to manage patients whose problems are not so simple as they first seem.

Sometimes what a patient thinks is a simple problem is not. For example, a patient may come to the clinic for the treatment of a sore throat, but actually have an exacerbation of chronic obstructive pulmonary disease.

Sometimes a patient with a simple problem has other, not so simple problems of which they are unaware. For example, a patient with a bladder infection may also have undiagnosed, but uncontrolled diabetes.

Why would in-store clinics not cope well with such patients? One reason is that nurse practitioners, no matter how able and well intentioned, do not have as extensive training and experience as most primary care physicians. They may not know all the possible causes of common complaints, and not recognize subtle symptoms and signs that indicate more complex problems.

Another reason is that the people who developed the in-store clinic model may not understand the health care context well enough to appreciate these issues. Many people pushing in-store clinics seem to be business executives with no on the ground health care experience. For example, we previously noted that Michael Howe, the CEO of MinuteClinics, a subsidiary of CVS Caremark, was "recruited for his leadership experience," but this experience mainly seemed to be in the restaurant business. Howe was the former CEO of Arby's Inc./Triarc Restaurant Group, and before then an executive for KFC, according to this article in the Minneapolis/ St Paul Business Journal.

My concern about how well the people designing in-store clinics understand the health care context was highlighted by today's Boston Globe article that described how Massachusetts state regulators have just cleared CVS Caremark to open MinuteClinics in the state. Here are the crucial two sentences:

The panel's members also wanted hand sanitizer available at the clinics and restrooms adjacent to the facilities so that patients don't have to walk across the store. All these provisions were incorporated in the regulation adopted yesterday.

This article implies that CVS Caremark MinuteClinics will not have any plumbing within the clinics proper. They will not have sinks and soap dispensers, and they certainly will not have toilet facilities. How adjacent such facilities would be is unclear.

Why is this a big problem?

Take a look at the list of conditions which MinuteClinics claim to be able to treat. They include "bladder infections," "pink eye and styes," and a variety of skin infections.

Diagnosis of bladder infections requires a urinalysis, and usually a urine culture. How will MinuteClinic patients provide urine samples? If patients are required to go out into the CVS store to find a bathroom, produce their sample, and go back to the clinic, how many would refuse out of embarrassment? If patients with bacterial urinary tract infections fail to provide urine samples, they might not get needed treatment. If patients without such infections fail to provide urine samples, they might get unneeded antibiotics. Also, would waiting for patients to provide urine samples slow down patient flow so that MinuteClinics become HourClinics?

It gets worse. "Pink eye" is often caused by viral conjunctivitis, which can be highly contagious. Health care professionals can cut down on its spread by thorough hand washing after seeing affected patients. (This is one of many reasons that you will almost never see an American doctor's office examining room without a sink and soap.) But MinuteClinic nurse practitioners will not have a sink and soap within their clinic, and will have to go out of the clinic, and wash their hands in whatever facilities CVS provides. Because of this inconvenience, and the time pressure inherent in the MinuteClinic concept, would the nurse practitioners sometimes fail to wash their hands when indicated? If they would not wash their hands, they would be at risk of transmitting viral conjunctivitis to other patients, and acquiring it themselves.

It gets still worse. MRSA (methicilin-resistant staphylococcus aureus) infections have been on the rise. MRSA can cause skin infections that are not specific in appearance. It is likely that some patients going to MinuteClinics for one of the common skin infections that the clinics are supposed to be able to treat will really have MRSA. For the reasons above, would the nurse practitioners fail to wash their hands after every such patient they see? If they would not wash their hands, they would be at risk of transmitting MRSA to other patients, or acquiring it themselves.

The failure of the executives of MinuteClinics to make sure that every one of their clinics has an in-clinic sink and toilet suggests that these executives really do not understand the health care context well enough to appreciate what they are getting into. I worry about what unrealistic assumptions have gone into the development of the in-store clinic concept.

The common business school notion that an executive does not need to know anything specific about the nature of the business he or she leads will continue to plague health care, maybe this time, literally.


MedInformaticsMD said...

Roy, I believe your observations are quite prescient.

I actually oversaw a satellite "urgicare" center started as an experiment by Philadelphia's Jeanes Hospital, where I was Director of Occupational Medicine, circa 1990-1. It was located about 15 miles away, near a large shopping mall and was called "Care Now."

Care Now did what these new centers propose to do, but a physician was always present along with the "physician extenders." And, of course, there was a dedicated bathroom!

I cannot imagine how these "pseudodoc-in-the-boxes" will work considering the myriad complexities and potential traps of outpatient medicine.

However, if your knowledge of medicine is via doctor visits where the doc puts the stethoscope on your chest, taps your back a few times, and writes a script on his little pad, then you might think you could set up an urgicare center in a teepee on the town square with an earthen pit nearby for the bathroom.

After all, how hard is it to accomplish nuclear fission on your kitchen table if you have all the right management credentials?

Hoots said...

Excellent points all. No argument from me. The quality of "Minute Clinic" care is by definition not only substandard but possibly dangrous.

But the state of medical care is already substandard and dangerous because so many people in need of medical attention self-treat and go without professional attention altogether. Some attention, even from a PA or RN, is better than none at all. How many sick people take antibiotics from a prescription written for a sympathetic friend who started getting better, or endure treatable conditions that for which such treatment might return them to a much-needed job?

And in the case of the much-discussed flu pandemic, isn't an improved infrastructure of places to administer vaccinations of some value?

sukichaz said...

We all know that simple uncomplicated office visits are the bread and butter of medical practices and most docs only spend 5 minutes and barely examine the patient. So forget about the myriad complexities.

And let's assume there is a bathroom since most people know that's a given if a patient is giving a urine specimen. That blows away most of your post.

As for diabetes, you guys have probably never done a urinalysis yourself, you may have a poorly trained staff member doing them (since doctor's offices are not regulated by the health department the way retail clinics are, and can even have the office secretary doing sensitive testing procedures, thereby risking diagnostic errors). A urinalysis also includes a test for glycosuria.

So it looks like you don't score any points this round.

SamEyeAm said...

I just saw a patient today referred from a minute clinic with presumptive viral conjunctivitis. Her symptoms today were mild (early) but over the past month I have observed a mini-epidemic of a fulminant conjunctivitis, highly contagious, with at least a 2 week recovery period. I recently put out a broadcast email to all members of my county medical society. Today when I saw this patient referred from the minute clinic, I made a special point to call the nurse explain all of the above and suggest her staff cidal wipe down all contact surfaces in patient waiting areas and exam room.
Ironically I prefer patients referred from minute clinics over those referred from primary care physician offices. Most of these physicians will utilize physician assistants and nurse practioners so what is the difference? In a busy practice NONE. While doctors prescribe medications such as antibiotic drops, few have the training, experience, and equipment to get it right consistently. Why not send the patient to me and let me get a clean shot at diagnosing and treating the patient with a fresh disease? In my experience, the minute clinic nurses let me do that more often. Ultimately the minute clinics will act like a triage referral resource only if they find primary care, specialists, and subspecialists to refer patients in a "minute".

The inefficiency of emergency rooms is directly related to the illogical inefficient construct of modern ER. The ER doctors hold patients "hostage" in the emergency room over utilizing resources, treatments,diagnostic modalities for a majority of non-emergent and sometimes emergent care when the pipeline to primary care, specialists, and sub-specialists is artificially constricted.


Zagreus Ammon said...

You're right on the money. I am concerned about the diversion of resources and the fact that physicians are not playing on a level playing field since they are generally not in a position to refuse care of complicated patients as MinuteClinics can accomplish structurally.

It would help if physicians could sell medications directly to the public, at least in terms of leveling the playing field.

Retail people are absolutely fantastic at segmenting a market to assure a better operating margin. But I am not sure it accomplishes improved health outcomes by free market methods, as it is intended.

More at:

Roy M. Poses MD said...

My, my, it's fascinating that posts about in-store clinics always inspire more comments more quickly than most others.

Hoots, I agree that there is a much larger problem with access to care. But will in-store clinics, which at best can handle only a few very simple problems, really improve things much?

Sukichaz, some office visits are simple and take 5 minutes, and some are horrendously complicated. And it's hard to predict which will be which until the physician sees the patient.

Why are you assuming that MinuteClinics intended to provide bathrooms, when the regulators had to put in a provision to require bathrooms nearby? And how nearby do you suppose that will be?

Personally, I did hundreds of urinalyses during my training. And of course the urinalysis tests for glycosuria, but that is not a sensitive test for diabetes.

Score the points anyway you like.

SamEyeAm, I suspect you are right that primary care physicians should refer more patients with conjunctivitis. But I do think that most physicians' offices that include nurse practitioners or physicians' assistants offer more supervision and backup to them than do stand-alone in-store clinics.

Why do you suppose there is a shortage of primary care doctors? You might want to look at what we have posted on the RUC.

Zagreus Ammon, you are right that primary care physicians cannot structurally discourage complicated patients, but it is our job to take care of complicated patients. The problem is that we are not reimbursed very well for doing so, and meanwhile, are buried in paper-work and bureaucratic requirements thought up by some of those brilliant business managers.

NotAllPatientsAreStupid said...

Your comparison assumes that Minute Clinic patients would have equal access to a doctor, same day, on weekends, at night, or at all. For most its a convenience.
Even patients with health insurance may choose a Minute Clinic to avoid long waits for an appointment -- who can wait a week when their kid has an ear infection? For me, with a high deductible plan, I would rather pay $40 for an in-store clinic and be seen the same day to handle minor problems, than have to wait a week, take a half day from work, pay $180 and get the same result.
Minute Clinic nurse practitioners and PAs are very good at sending reports to your primary care doctor, providing follow-up instructions and referring cases that are not within their scope. (Certainly more thorough than many primary care doctors I have had over the years, who are often impatient and inattentive.)

Anonymous said...

I am a PA and work in a retail based clinic. I am experienced and am very comfortable in all I do. Our stores have sinks and bathrooms where our patients are able to go to if a urine sample is needed. We have strict guidelines that allows us to provide the best care we can to our patients without causing harm. All of the extenders have a low thresthold for treating patients and we refer out alot of patients that do not fit our strict guidelines. We are all experienced providers and we are able to judge very well when a patient needs to be seen by PCP, ER, or UC. Our doctors (yes, there are more than one) are always available by phone call if needed. Every chart is reviewed by our doctors within 24 hours and if any problems, they let us know and the patients. Every patient is screened for medical problems and allergies and the PCP is sent a copy of the visit, if the patient has one. If not, we always give the patient a list of PCPs in the area and go over the list with the patient. All the patient's instructions are printed out for the patients and we spend a great deal of time going over OTC meds, RX meds, and recommendations. All patients are urged to follow-up wtih their PCP if symptoms persist. Patients with chronic medical problems are asked to follow-up with their PCP or not even seen and referred directly to their PCP. We even call the PCP and make appointments for our patients, and get same day appointments for our patients, if it is urgent and they need to be seen by PCP right away. I see so many patients who are sick and are unable to see their PCP for 3 days or even longer. A child with an ear infection should not have to wait 3 days to see their doctor. Someone with strep throat should not have to wait. I am very strict when it comes to prescribing antibiotics and if a patient is persistent on wanting them, they are instructed that they need to follow-up with their PCP if they feel their condition is more serious. All children are instructed to follow up with their PCP within 1-2 weeks for a recheck, especially for ear infections. I could go on and on and on about how the model of care here is superior and for you unexperienced people who are bashing this model of care need to find out for yourself. I don't appreciated being called substandard and possible dangerous to patients. Before you accuse, maybe you should visit a clinic for yourself.

Anonymous said...

It may come as a surprise to you doctor, but I prefer the NP to the MD at the family practice I go to when I am sick.She is very thorough and actually listens to the symptoms for more than 2 minutes. NPs are well educated along with being well intentioned. An NP can look up things they do not know, just like an MD. Maybe you should look at the root problem of why people are utilizing minute clinics. They probably can't get through to your office.
I am not in favor of minute clinics because I think people need more follow up and prentative medicine.You do not receive that at a minute clinic. As a previous person stated a simple problem could be an indicator of a bigger problem. Just don't blame the NPs.

Anonymous said...

I, for one, do not see the support these clinics provide. I have visited our local clinic twice, waiting about 30 minutes each time and never received any medical care.

Was I searching for prescription pain meds or psychotropic drugs - no!

The first time I went because I was moving in two weeks and could not get in with a local OB/GYN. I am 34 and had a complete hysterectomy three years ago. The NP would not see me for a chronic condition like menopause. A simple estrogen prescription was refused.

The second time we visited, my husband was bitten by a fly and his face was swelling on one side. The NP said, "I cannot help you. You have to go to the local Urgent Care."


Sarah said...

I would like to make a comment about your complaint of retail health clinics not treating what you came for. Retail health clinics operate under very strict guidelines and offer a limited number of services; absolutely anything outside of this must be referred out. All NPs and PAs employed at these facilities must diagnose and prescribe based on these guidelines, nothing else. It is absurd to think you can walk up to a minute clinic and get prescribed an estrogen pill. To a simple minded consumer it is "just an estrogen pill" If it were a "simple estrogen pill" It would not have taken the MD or the NP 6-10 years of medical training to be allowed to prescribe that "simple pill". Retail health clinics are not fit to provide women's healthcare, period. If you knew anything about medicine at all you would know that a sting to the face can have serious complications, swelling of the throat etc..The public needs to know there is a reason these retail healthc clinics have strict guidelines! People should not expect everything from these clinics.

Anonymous said...

First of all, let me say that I am CRNP and worked a few years ago at a MinuteClinic. I also was a patient once at another retail clinic. I do believe that with experience (I have 22 years) that NP's are capable of providing safe, effective care, even in more complex situations. The problems with the retail clinics seem to arise in at least two areas: 1) The patient presenting with a problem must already formulate a presumptive diagnosis in order to be seen,which may not correlate directly with the underlying problem. The NP's are extremely limited in what kind of tests or exam components they are permitted to perform, as an example, last I knew the exam took place only in a chair, and the NP was not permitted to evaluate abdominal complaints.

As a patient with a severe sore throat, +4 tonsils with exudate, anterior cervical adenopathy, a frontal headache and a fever uncontrolled by ibuprofen alternating with acetaminophen every 2 hours (and a history of splenectomy), the NP was not permitted to prescribe an antibiotic for me until the throat culture was back. Overnight, I developed the inability to swallow and was admitted to the hospital with a partially obstructed airway due to strep G tonsilitis, a white count of 26,000, and required IV Zosyn, steroids and morphine. I was there for 4 days. I do not enjoy saying this, but in both clinics, a monkey could almost have done the job.

The underlying ploblem in all of this is that we have poor and inaccessible health care available to most people in the US. And...if we don't take care of it...someone else will.