Convenient Care Clinics: Much Ado About Nothing

During the past 5 years, a growing number of consumers have turned to convenient care retail clinics in their search for accessible, low-cost, quality healthcare. These clinics, often found in drug stores and discount shopping centers, are staffed primarily by nurse practitioners (NPs) who follow protocols to treat the most common primary care complaints and refer more complex problems to other providers. Convenient care clinics (CCC) have dramatically improved access to care for patients who have no insurance or who experience other barriers to healthcare. Not only are the clinics convenient, but they also allow patients to shop while waiting to be seen.

For the most part, CCCs have succeeded financially, although poor forecasting of patient demand, bad management decisions, and the declining economy have taken their toll on some clinics. In some settings where physician providers were added, increased operating costs were prohibitive to staying in business. NPs have accomplished the goal of providing care for nonurgent primary care concerns, and in doing so, they have decreased pressure on local emergency rooms that would otherwise see many of these patients.

Of all visits to CCCs, 90% involve 10 conditions: upper respiratory infections, sinusitis, bronchitis, pharyngitis, otitis media, otitis externa, conjunctivitis, urinary tract infections, and immunizations and screening tests or blood pressure checks. Most patients are seen by the provider within 15 to 20 minutes of computer registration into the system. For each chief complaint, there is a computer-generated protocol that the practitioner uses to diagnose and treat the patient. If the diagnosis falls outside the protocol, the patient is referred either to a local clinician who has agreed to work with the clinic or to the nearest emergency room, depending on the urgency of the problem. Each CCC also has a collaborating physician whom the NP can contact to discuss a particular case.

Clearly, the scope of practice in CCCs is narrower than the NP's preparation and education would ordinarily allow. But NPs choose to practice in these settings for a variety of reasons. Some like the independence afforded by the role, the hours, the benefits, the collegiality, or the ability to enhance their expertise with a limited number of conditions. Some NPs who have experienced the rapid pace of family practice clinics enjoy the extra time available in the CCC to offer needed education to the patient. With a limited number of conditions to treat, the NP encounters few obstacles to practice.

Not everyone has been happy about the CCC concept. Some organized medical groups have opposed CCCs, citing concerns related to continuity and coordination of care and lost revenue. As a new business delivery model, clinics have attracted the attention of researchers who have studied and refuted many of these concerns. Researchers have documented, for example, that there is little disruption of primary care relationships when patients seek care in CCCs. Most CCC patients do not have primary care providers (PCP), so there are few relationships to disrupt. Furthermore, most patients are 18 to 44 years of age, a group that otherwise would fail to seek care until more serious symptoms developed, increasing the costs of treatment.

Concerns about communication barriers between providers and patients have largely been resolved. All clinics either provide the patient with a written summary of the visit or fax a copy of the record to the patient's PCP. The financial impact from lost revenue is potentially offset by the PCP's ability to accept a greater number of complex cases whose reimbursement rates are higher than those of the simple acute cases handled in a CCC. The CCCs are also a potential source of referral of new patients whose health concerns fall outside the scope of services offered by the clinics.

In response to articulated concerns about CCCs, standards of care that address scope of service have been developed by the convenient care industry. For example, CCCs do not see children younger than 18 months of age. Electronic medical records provide ready access to visit summaries for PCPs, and all complex cases are referred to appropriate local healthcare providers.

The rapid expansion of CCCs into a variety of settings suggests that these clinics are here to stay and represent a unique way to offer affordable access to healthcare for underserved populations. As the number of physicians entering primary care declines, NPs have demonstrated that they can deliver this type of care, and the CCCs have become an excellent showcase for their skills and talents.

Special thanks to Marilyn W. Edmunds, PhD, NP and Laurie Scudder, MS, NP

Is It Okay to Attend a Patient's Funeral?

Lily, a bright, compassionate medical student deliberating on choice of medical specialty, asked me if I could tell her about one of my most meaningful patient experiences. I reflected for a while and then began to describe attending a patient's funeral. In a surprised tone, she interrupted with, But I thought we weren't supposed to do that-go to a patient's funeral? Isn't that getting too close, too personal?

It has been many years since I attended my first patient funeral, yet I still recall being afraid of the experience itself, not knowing what to expect-a different culture, religion, part of town. It was loud, with exuberant singing, praying. The congregants raised the roof with their energy. When I got home, I told my partner-that's how I want to go out of this world. Wow! They made it joyous, not the depressing ceremony that I had anticipated.

On my drive to a subsequent funeral, I worried about what the family would think about me. I had seen Ms. Tolly in my primary care clinic for years. While I was not involved with her inpatient care at the time of her death from cancer, would the family be accusatory-with thoughts that perhaps I had missed an opportunity to diagnose their mother earlier? Would they be angry that I was not at the bedside when she died? I arrived at the funeral home, took a deep breath, and wished I had a companion to stand by me. My patient's sister and children greeted me kindly. My fears eased, and I felt comforted as the family expressed genuine appreciation for the years of medical care that I had provided to Ms. Tolly.

A few days after my encounter with Lily, one of my dearest patients, Ms. Sanchez, passed away. I was extremely saddened by her death, though not surprised. She had many chronic health problems and had suffered a life-threatening stroke several weeks earlier. One of Ms. Sanchez's grandchildren contacted me to let me know about the funeral on Saturday. I had many commitments, in particular to spend some quality time with my young children. I decided that I would go to the funeral briefly, express my condolences, and leave.

After crying most of the way to the funeral, I recognized that I was using my family somewhat as an excuse-I was genuinely sad and reluctant to end my relationship with Ms. Sanchez. I had visited her in the hospital prior to her discharge to a long-term care facility. Now I was going to finally meet the family about whom I had heard much and seen many photos. I recognized her son Pepe immediately, wearing his Hawaiian shirt and lei, and Charlie, her grandson, who had recently graduated. Here was the family that she so loved and that loved her. Multiple family members recognized me as her doctor, hugged me warmly, and exchanged stories. For the first hour of the funeral, family members recounted her life, described how her compassion had affected everyone there, and presented a slide show about her.

Not one person mentioned her many illnesses and how, despite these conditions, she had accomplished so much. The ceremony was truly enlightening, giving me a new perspective of my patient outside of the public hospital and renewing my awareness of all my patients as individuals-who live full lives with illness. I felt able to complete my farewell to Ms. Sanchez while opening doors for enhanced relationships with other patients.

I appreciate my patients for continuing to teach me beyond the clinic-to be less afraid of death itself, to understand that a patient's death is not synonymous with failure or culpability, and maybe most importantly to recognize that we need closure with some of our patients. So Lily, I think it is okay-you can attend a patient's funeral. It is part of caring for your patient and caring for yourself.

Special thanks to Joslyn W. Fisher, MD

Top 10 Annoying Patient Behaviors

Hey, we're people too. Here's a top 10 most annoying patient behaviors:

1. Skipping appointments;

2. Being verbally abusive with staff. I'm sorry you don't feel well or having a shitty day, but don't take it out on my staff;

3. Having poor compliance with medications or treatment. And they wonder why their condition isn't improving;

4. Being late for an appointment;

5. Not knowing their current medications. Inexcusable;

6. Family members who insist on the highest level of care for terminally ill patients and who later complain of the cost of that care;

7. Drug seekers (you know who you are);

8. Noncompliant patients;

9. Patients who tell the doctor how to treat them. So why are you here wasting my time?

10. Patients who answer their cell phones during office visits. But you'll shut off your phone in a movie theater?

One patient behavior -- that of missed appointments -- not only is annoying but also cuts into my wallet. No-shows and same-day cancellations kill a business. Just like the auto repair shop, we have a fixed overhead (eg, rent, salaries, malpractice insurance) that eats up 70% of the day's gross collections. That's why your charged when you no-show.

Patients frequently research their medical conditions on the Internet. I don't have a problem with it as long as the information used is credible and helps supplement their understanding of their disease process. This can work especially well for a focused problem.

Even as a doctor, you can only stand so much. When this happens I jump on my '52 Vincent and just ride.

Physicians Rise Up to Save Primary Care

"I laugh every time they discuss healthcare policy," says a family medicine doctor. "The real issue should be how to save primary care."

Recent articles in the medical and lay press have focused on the growing shortage of primary care physicians in the United States and the crisis that that shortage is causing in the nation's healthcare system. A long and animated discussion on Medscape's Physician Connect (MPC), a physician-only discussion board, sizes up the problem.

"The only ones of us left in family medicine are those that are too young to retire and too old to retrain into another specialty," says an MPC family medicine doctor. "The major reason?" he continues, "It's underfunded. Salaries need a major increase. I would say double at least, probably triple." A recent article in JAMA documented that family medicine, at $185,740, has the lowest average salary of the medical specialties.

"Primary care physicians are being relentlessly hammered each year. They are getting burned out, and many are going broke," says an MPC internist. A preventive medicine doctor comments, "In the UK, whatever the defects of the system -- and they are many -- they build around GPs, who get $230,000 a year plus 25% performance bonuses. And, of course, they don't have huge medical school debts. We have it backwards. The most valuable doctors -- primary care physicians -- get paid the least."

Money aside, for many MPC contributors, professional dissatisfaction stems largely from the burden placed upon them by insurance companies and Medicare and Medicaid, which demand that physicians comply with an ever-growing number of documentation requirements.

"The intrusion into medicine by third-party payers (better known as the insurance industry, Medicare, and Medicaid) has been coming since the '60s, but this effort to control costs has really become burdensome over the last 15 years," says an internist, "and it has not controlled costs and has not improved quality."

Another contributor remarks, "Every visit has its own catch-22, whether that's a prior authorization, a formulary, a HIPAA rule -- it never ends."

How can the system be changed? One family medicine doctor suggests that doctors largely stop accepting insurance and return to a fee-for-service, out-of-pocket system of payment for routine care. "Why are we even dealing with the insurance companies?" says one contributor. "Go cash-for-service. Supply and demand. As long as we play along, we are doomed to ever-decreasing salaries, increasing hours, and less job satisfaction."

"It makes no sense for insurance to cover routine office visits," offers another family medicine doctor. "If third-party payers no longer covered office visits, the cost of out-of-hospital healthcare would drop considerably."

"Overhead in primary care is ridiculous," says one contributor, "Let's get rid of the billing and coding system. Pay primary care doctors for time spent, by the hour, like lawyers."

One of the major overhead expenses in primary care is the skyrocketing rates of malpractice insurance, which many MPC contributors see as a major target for reform. "End the malpractice lottery," says a family medicine doctor. "Require a review board that has no conflict of interest to decide whether a malpractice case has merit. If it does, send the case into binding arbitration. Only if binding arbitration fails should the case proceed to a malpractice suit. Strictly limit lawyers' compensation and allow no payments for pain and suffering."

The level of dissatisfaction with their practice has led some physicians to advocate for change. "If we don't get politically active and start standing up for our rights and our patients' rights to quality care, then we have no one to blame but ourselves," says one contributor. He recommends that the AAFP or the AMA pay a number of doctors to go to Washington, DC, to lobby and educate lawmakers about how dire the situation has become for primary care physicians.

One internal medicine doctor is investigating the possibility of forming a physician's union. He initiated talks between his local medical society and the Service Employment International Union (SEIU). "Word has it," he says, "we will be sending a representative to New York to meet with the SEIU." He recommends that physicians spur their local medical societies to get involved in talks with the SEIU.

A family medicine doctor concludes, "Let's stop complaining and start coming up with specific recommendations for improvement. Let's be a voice for change."

Many MPC contributors have offered specific strategies for overhauling primary care. The following are some of their recommendations:

Eliminate multiple insurance companies and use a single payer. If a system of multiple insurances companies is retained, make the costs transparent, fair, and reasonable to encourage competition. Provide everyone affordable coverage for catastrophic care. Make office visits reasonably priced but require payment at the time of service. Require small copay from Medicaid patients to limit overutilization. Increase primary care physicians' salaries and award performance bonuses. Give primary care physicians the freedom to order tests and make referrals without subjecting them to red tape. Implement tort reform that limits physician liability, sends most suits into binding arbitration, caps lawyers' fees, and eliminates compensation for pain and suffering. Allow physicians to bill for payable hours, such as time spent with patients, in answering email, and in returning phone calls. Mandate that hospitals operate 16-hour-a-day centers offering urgent care to the working poor at reduced rates or risk forfeiting their tax-exempt status.

Special thanks to Nancy R. Terry medical writer and editor, Jackson Heights, New York

Stress Release

We've all heard that laughter is the best medicine but why was this phrase coined in the first place? Have you ever been so frustrated that you either had to laugh or cry? Do you remember that great feeling you had at the end of a good laugh?Laughter releases hormones that reduce stress in our bodies. Laughter increases the levels of healthy hormones that make us feel good. It increases our antibodies in our system and helps us to reduce the overall side effects of stress.

Laughter provides a good workout for our bodies. Often when laughing we use our belly's and shoulders as we give a whole hearted good old fashioned laugh. We increase our oxygen intake and the laughter encourages deep breathing which gives us an overall sense of well being.

Creating a distraction away from our day to day grind and allowing us to set our troubles in perspective laughter is indeed a good medicine.

Seeing the humor in a situation can often re direct our anger and even create a more positive environment in which to work towards a solution.

Laughter can often redirect a bad situation and help us in diffusing a stressful time in our lives or those of others.

Learning to look at the lighter side of things is often a great way to challenge ourselves to not take everything in life so seriously and to find new ways to solve problems and challenges in our daily lives.

So where does one go to find laughter? Often no further than ones own home. Look for the humor in every day things. Knowing the address of your local snow plow driver so that you can return the berm of snow he left in front of your driveway may not be feasible, but it might be fun to plan it out in your mind. It may even help to reduce your stress and frustration as you dig your car out of the driveway. No, it won't solve it all. It won't necessarily improve the current situation at that moment, but given time you will find the humor in the situation. You will be able to smile and laugh at it one day. Learning to call upon those memories in times of stress will go far in helping you to reduce stress.

Learning to smile when the going gets tough will help you to present a positive attitude, applying laughter to the situation will improve it even more.