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.