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"You're Sick, We're Quick":Store-Based Clinics
Have you had a medical checkup at a CVS pharmacy yet? You probably won't see a physician there. A nurse-practitioner or physician's assistant will do the examination. What they can do and diagnose will be limited but you won't need an appointment, just walk in. Does anyone want to talk about the ethics of the commodification or is it commercialization of medical treatment in the form of the store-based "convenient care" clinics? Read the
pdf file of the research regarding this form of healthcare by the California HealthCare Foundation. To me the ethical issues include "who owns the! patient"? "what are the standards of care?" "how is patient information shared and privacy protected?":"does a pharmacy which has a clinic within its walls have any conflict of interest with regard to the sale of medications?" You probably might find more issues. ..Maurice.
12 Comments:
The question "Who owns the patient?" needs to be put into its proper context -- a question of "collegiality" among members of the medical profession. It's not about making sure patients get the best care.
As for commercialization... Any physician who expects to be paid for services rendered is commercializing health care.
Standards of care present a more pertinent issue, I think. Of course, I don't have any evidence that the care provided by these walk-in clinics is of a lower standard than one finds elsewhere.
And regarding issues of privacy, there are laws on the books about this that would seem to apply across the board. Is the problem one of enforcement?
My cynicism reflects my view that the "health care system" is insular, protectionist, and profit driven.
Kudos to the above post. Medical "ethics" is simply a codeword for maintaining the physician monopoly. Indeed, Maurice's litany of woe is just blowing smoke.
1. Who "owns" the patient? The, excuse me, healthcare consumer does. Who takes ultimate responsibility for his care? The consumer does. What's wrong with that?
2.Standard of care is that of NP. What's so tuf there?
3. Privacy?!! Ha, ha. As if HIPAA protects anyone's privacy.
4. Don't surgeons who make money from expensive procedures have a conflict of interest when the recommend for performing a given surgery?
Trifles, Maurice--smoke and mirrors to hide the greed of your profession
But then what is the answer to improve our U.S. healthcare system which is, as generally agreed upon, needing repair or owerhaul? Would it be satisfactory to begin, as noted on another thread, to make all physicians public servants, like the trash collector or the postman, and have government pay them a fixed salary as their entire source of work income? And then what? How about the pharmaceutical and medical instrument industry, do they get off free with no control over their greed? I am not against the current concept of store-based healthcare, I just think that as something like this in its infancy, it should be a topic for informative and productive discussion. And as far as the codeword "medical ethics", fortunately, the majority of those professionally participating in the discipline of medical ethics are not physicians. ..Maurice.
This is not that new of a concept. In Minnesota, there have been quick med clincs in a grocery store (by the pharmacy) for a long time. You go for basic things like strep tests and such. They are faster and more effecient than an urgent care or making an approintment with a doctor.
As for the conflict of interest. Then what about hospital pharmacies? Most hostipals that I have been in in the US have pharmacies in them.
I have also begun to appreciate the American medical system more after going to the doctor a few times and seeing hospitals here in Dublin Ireland.
Heidirific, I would be most interested in learning about your experiences. I wonder if you could post here some generalizations you observed in the differences between the American medical system you have witnessed or experienced and the system you find in Dublin. ..Maurice.
Maurice, I plan to post about the hospitals soon on my own blog so I'll leave those differences for now.
Differences:
1. Education level: doctors have less formal training in Ireland
2. Gynalogical exams aren't as frequent for females. My doctor was shocked that I got yearly pap smears (don't know if that is necessary or not but they do a graduated scale here where I would be on every two years I believe).
3. Doctors offices. Most don't have computers (not that they are really needed). Records are kept by hand and my doctor takes minimal notes during my visits (as opposed to typing all the notes during my visit).
4. Doctors offices: I have not been to one that has a lab in it.
5. Need for hospitals: you must go to the hospital to have blood drawn or any test (e.g. mri)
6. Time taken for surgery: An acquaintance was on a waiting list for 2-3 to have knee surgery. Another friend went to the UK to have same surgery because she couldn't wait above 2-3 years and it was cheaper.
7. Frequency of going to the doctor: I pay a 50 Euro copay regardless of insurance status. Also, prescriptions are only written for 6 months so for chronic medicines, you have to go to the doctor or pay a fee for a "repeat" prescription (no just calling it in with phone consultation).
8. Antibiotic use. Doctors prescribe them far more frequently here than in the U.S. from my experience. I have chronic sinus infections and I've been given antibiotics when I haven't felt I've needed them. I needed a nasal spray instead.
9. Doctors ask what you want. I've had doctors ask me what I think of their proposed care instead of saying, this is what we're doing.
Do you want me to go on? I've almost made a blog post...
Heidirific,interesting.. though I am not sure all this represents "bad" medicine. With regard to #9-having patients respond to a physician asking about what does the patient think about the proposed care is the mechanism of informing the patient where the options for treatment are presented along with what the physician thinks is the best for the patient and then having the patient consider whether to agree with the doctor. For a doctor to simply say "this is what we're doing" and without allowing the patient to input their opinion is a form of frank paternalism which has been abandoned in the United States for a number of years. ..Maurice.
I didn't say all the differences were bad. As for #9, I didn't explain it well. I have seen 3 different doctors since I moved to Dublin in June 2005 trying to find one that I like. It is more that I have had doctors ask me if I think I have a sinus infection and have found myself telling the doctor, no I don't think it is. He then says to try antibiotics anyway even though the last round didn't work. I then remind him that in the past a nasal spray helped more. He considers giving me a nasal spray. I ended up with "try the antibiotics" and if the first week doesn't work, take the second and try the nasal spray.
I agree with discussing things with a patient but this is different. It feels a bit condescending at times (mostly because they talk down to me) and more the Irish way of passivity. The Irish have a way of saying overly politely, actually the words of asking, what will happen. So, to an outsider, they are asking what you think where in reality they are telling you how it will be.
Oh, also in the States I have had many doctors tell me what they think and what the course of action will be. I sometimes would tell the doctor what worked in the past but they would or would not have gone with the same course of treatment or not. (I am mostly talking about sinus infections here.) I have also had American doctors completely disregard my symptoms and history because I didn't have a "critical" symptom which is actually quite a rare symptom.
Another difference here in Dublin is the reliance on less objective measures. The doctors haven't taken my temperature. They haven't checked my white blood count to check for infection. They do a brief examination (sometimes don't even look in my throat or nose for sinus issues), take a brief history, and give the drugs.
I probably also should note that I was one of the lucky ones in the States. I had decent health insurance and had found a good doctor who wasn't afraid to refer even though I had an HMO
Lets let the marketplace decide if it can work. Personally, I would never work in one, though possibly I might go to one. Possibly, well maybe slightly possibly, well, nahhh. Never.
This is a great blog, Dr. Bernstein; I came to it after Googling "I hate doctors". It's refreshing to see a member of the medical profession engaging in a reasoned debate in a public forum.
In regards to the question of nurse-practioners in your local pharmacy, I have no problem with it.
In my experience (both as a US citizen and as an ex-pat who lived in the UK for 15 years) it is usually the PA/ nurse-practioner/midwife who seems to be on top of a patient's health, more so than the doctor. They actually listen to what you, the patient, are saying.
When I was pregnant with my first child, it was the mid-wife who saved her life during the labor process. I was being induced and the admitting intern doctor mistakenly gave me quadruple the dose of Pitocin needed. As you can imagine this was like going from 0-80 in a few minutes.
The mid-wife questioned the intern, who of course arrogantly stood her ground. Thankfully, the mid-wife went off and found the head of the ob/gyn unit himself. He came in, saw what was happening (i,e, my daughter was in serious distress) and immediately took over.
It all ended well; the baby was delivered without a ceasarean and with no damage. I was extremely angry however, and made an official complaint about the intern.
The very same doctor that had seen the incompetence for himself and saved the day, then condescendingly gave me a lecture on how lucky I was that they had saved my baby and how I should just be thankful for that. Shut up basically and never-mind that it was a Doctor that had caused the problem in the first place. Move along now, please, no more whining from you.
I've had other experiences where nurse-practioners have caught doctor's mistakes, and pharmascists have noticed wrong dosages on prescriptions, et cetera. Now, I would much rather see a nurse than a doctor if I can get away with it.
As far as conflict of interest with regard to the sale of medications, how many doctors routinely prescribe medicines that their friendly big pharm rep dropped off only yesterday? Doctors in the US seem to just want to write a prescription and get you out the door as quickly as possible.
As has been said by others on this site, the problem is with the system itself here in the US because it IS profit driven. Perhaps making the medical industry MORE competitive and less insular might shift the balance, I'm not sure.
I don't think that all medical professionals are incompetent boobs that are in it for the money, but I DO think our system is broken.
Thanks Dr. Bernstein, for being one of the good guys. Keep up the good work!
Speaking to the question of possible conflict of interest, the prescription from MinuteClinic NP's has printed on the bottom "May be filled at any pharmacy". Also, the electronic message board outside the clinic has the same message.
I coined the slogan You're sick we're quick"
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