doc in a box mystery

[walkitout]

Actually, this is the retail clinics debate that is raging, which is a little different from the doc in a box which I have known and loved for lo some years now. I got my scuba physical at a doc in a box. I went in for a mono test (turned out not to be mono, but rather likely back-to-back viral colds, which is what I suspected, but when I run a low-grade fever that long, I start to wonder). I went in for a UTI. I got my blood test for the marriage license at one. I forget what else. I have had _good_ experiences at these places; they listen, they give evidence-based-care, they don't try to talk me into something I don't want to do. All in sharp contrast to my previous experience with PCPs (other than the nurse-practitioner I went to for gyn stuff for years).

One of the articles at Health Affairs is available for free:

http://content.healthaffairs.org/cgi/content/full/27/5/1299

And it's worth reading. The other one is not available for free, which is sort of a bummer, but there's some secondary coverage. A retail clinic is essentially a doc-in-a-box, only in a CVS or Wal-Mart or Walgreens or whatever. Which means there's someone there who can take blood, run a quick-strep or quick-UTI test, take your blood pressure blah blah blah _in the evening_ and _on the weekends_ as a walkin. For a reasonable amount of money, and they may even be willing to bill your insurance for you. Then, instead of having to make yet-another-trip to fill the resulting abx prescription (if you turn out to have strep or a UTI or whatever), you can just fill it at the drugstore you are already basically in and go home and be sick in peace and quiet. They'll also do immunizations; it's unclear whether they'll do travel clinic/scuba physical kind of stuff the way the doc-in-a-box does. At least some of them will do minor trauma stuff (sew up a cut or whatever). All a _huge_ win over waiting weeks for an appointment at a doctor or paying an exorbitant amount of money for the privilege of waiting hours at an ER (altho, to be fair, whenever I've gone to an ER or urgent care outpost, I've gotten swift, great care; I have Read Scandalous Articles, however).

Interestingly, in response to this new form of competition, some PCPs and hospitals have actually taken to offering walk-ins, same-day appointments (maybe _this_ is why Milford Family Practice is so cool?), clinics open on evenings and weekends, etc.

Here's what I do not understand. There are a _bunch_ of people out there flipping out about how these are horrible services. They seem to have two items wedged up their asses: (1) over prescribing of abx and possibly other drugs because they're trying to raise money for the business (the drugstore) in which they are operating and (2) not having a PCP and possibly therefore evading care that you Should Have (like cancer screenings).

I haven't ever _been_ to one of these retail clinics; I'm operating on the assumption that they run somewhat like the doc-in-a-boxes do/did. And those guys don't freaking over prescribe abx. PCPs over prescribe abx, because they don't want their regular clients pissed off at them and/or going elsewhere. No relationship = no threat. The docs working the clinic will only prescribe is they think it's justified. As for the evading screening issue, I think that's fairly bogus, given that immunizations, blood pressure and cholesterol screening are some of the common uses of these mini-clinics. The AMA has ginned up some bizarre fear about the clinic drumming up business for the pharmacy, which I think is pretty rich given how into-bed-with-each-other Big Pharma and the AMA are. You want to talk unnecessary prescribing of dangerous drugs as a fund raiser? Mini-clinics aren't where _I'd_ start.

From where I sit, these things look Great. Maybe not such a great idea if you're seeing a bunch of other doctors and don't communicate what you're already taking from elsewhere, but if you aren't regularly involved with the medical system and are just dealing with a stand-alone problem like a UTI or needing a tetanus shot for your two weeks in the wilderness, or you want to know if your killer sore throat needs abx or just some extra sleep and fluids, where's the harm? And honest, that looks like _exactly_ what's happening here.

Why is _anyone_ upset about this? I don't even see it particularly cutting into the local primary care practices business, and anything that can reduce the primary-care load on tertiary facilities _has_ to be regarded as a Good Thing, right? Is there some kind of social faux-pas that I'm missing?

Comments

[ethelmay.livejournal.com]

I lurk on a pediatricians' list where they get pretty passionate on this issue. I seem to recall their having some good points, which naturally I don't remember very well as it wasn't an issue I was wildly interested in at the time. I can look at the archives when I get a minute -- I think the main thing was continuity of care and the possibility that people would never get really complete physicals and someone looking properly at repeated complaints of such-and-such that might indicate so-and-so. It's a question of having context. Same reason that on matched populations midwives are likely to provide better care than OBs overall, with better stats to prove it, even if they ask you roughly the same questions and run roughly the same tests and so forth.

I wouldn't count on everyone to know when their minor complaints really were isolated events and when they weren't -- I keep thinking of the beginning of Betty MacDonald's _The Plague and I_, where she goes to about five different doctors about her various complaints, tells each one only what she thinks that specialist needs to know, and all of them say it's no big deal. Finally she goes to her sister's husband, who's an internist or something, and she actually tells him all her symptoms at once, and he immediately figures out she has tuberculosis. (Of course she also hit some lousy specialists.)

continuity of care

[walkitout]

I guess I just don't worry about the continuity of care issues in the retail clinic context -- these all look so obviously like one-off events. Even if you were coming in with strep throat ever 6-24 months, would continuity of care have an impact? I could see recurrent UTIs going a couple different ways -- maybe with continuity of care, a provider would have a (potentially very embarrassing all 'round) discussion about your sexual practices and bathroom habits and so forth that might resolve the trend. But the recurrent UTIs might be totally unrelated, and continuity of care in some circumstances leads to endless, increasingly dangerous testing.

Betty MacDonald's TB problem is a tricky one. On the one hand, if you go consult an expert and don't tell them the whole story, there's a problem. On the other hand, if you consult and expert, and distract them with a bunch of irrelevant, unrelated symptoms, you can really muddy the waters. I guess I could construct arbitrary cases that would cause problems either way and I have no real sense of which is more prevalent, altho I tend to guess that mostly-healthy people who develop a specific problem in a well-defined time frame (whether that's an ear infection, a UTI or inadvertantly slicing into their finger while making dinner) aren't going to see any benefit from continuity and might be inconvenienced and could conceivably be harmed.

The pediatrician situation is _really_ an interesting one. Physicals have been so repeatedly shown to be useless wastes of time for basically everyone -- except well-baby care, which still seems to be well-received and I think perhaps justly so. But as someone with exercise induced asthma married to someone with exercise induced asthma, it's very high on my list of goals to avoid getting into a pattern of drugging or otherwise medically managing this phenomenon in our son. So we just don't mention it when we go in, which sort of puts us in the Betty MacDonald category.

Nice to hear that I have correctly identified one of the major issues (continuity of care and/or preventive health checkups).

I agree on the midwifery model vs. the OB/GYN model, altho I would note that the fewer default tests probably has an impact as well. In terms of outcomes, no prenatal care strategy has fulfilled its initial promise, unfortunately, so I think the real win with midwifery model of care is its treatment of labor as physiologically normal and Not To Be Disturbed, more than anything else.

Re: continuity of care

[ethelmay.livejournal.com]

I poked around a little in the archives, and the reactions were actually more mixed than I had remembered. There were anecdotes both ways, some clinics that were well run and some really poorly run. One guy had worked in a fairly bad one and basically said ugh. Some of the complaints about the bad ones were "cookbook care," too many tests ordered, and lack of anyone with pediatric experience on staff. I didn't actually see all that much about continuity of care, though there were other conversations about that. But I don't pretend to have done an exhaustive search.

Re: continuity of care

[walkitout]

Lack of pediatric experience in the staff sounds like a problem, given that I would expect a fair amount of kids being brought in with upper respiratory or whatever. Too many tests ordered is a little surprising, but apparently that can happen anywhere? Interesting that one of the guys had worked in one and thus knew it from the inside.

I gotta believe the providers in a retail clinic are all staff; I wonder if they are part-time, full-time or contract?

here's a 2004 study of continuity of care for well-baby visits

[walkitout]

http://lib.bioinfo.pl/pmid:15173462

"RESULTS: Nearly all young children aged 4 to 35 months in the United States (98%) have a regular setting, but only 46% have a specific clinician for well-child care."

I read this as strong confirmation even in the case where I would regard continuity of care in an otherwise healthy individual as having substantial value that _most_ babies already don't have continuity of care in terms of person, and going to a retail clinic could provide as much continuity of care in terms of location as other approaches.

Possibly I misunderstood.

This was definitely our experience with T., even before we moved back to New Hampshire. During the first year, he had four or five different providers of well-baby visits after leaving the hospital. The midwives did a couple of weight/feeding/etc. checks at home. Then we went in to see the ped who saw him originally in the hospital, and who really annoyed the hell out of me, so we switched for a family practice doc at the same clinic. She was awesome, but she was a resident. When her rotation was over, we were switched to someone else.

ETA: a bit further down:

"Only half of young children in the United States are reported to have a specific clinician for well-child care. Low rates of continuity are found across health care settings. Furthermore, not all parents of children with a continuous relationship exercised choice, particularly among children in safety net health care settings. These provisional findings on a new measure of primary care continuity for children raise important questions about the prevalence and determinants of continuity."

Clearly, the authors feel differently than I do about what this all means. Our experience would come under the heading of "managed care", since we were at Group Health at the time.

Maybe general practice docs are over-qualified...

[(Anonymous)]

http://policymatters.net/?p=336

"The medical system in the United States is amazingly responsive to the most complicated diseases; but as far as general medications are concerned do we really need to go through the insurance companies and amazingly busy doctors to get the right medicine?"