Oh Henry
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Last month, Massachusetts moved forward with plans to allow in-store health clinics to open up throughout the state; think CVS with its own NP doling out antibiotics. According to John Auerbach, Commissioner of the Department of Public Health, “the goal was to give patients with relatively minor illnesses access to a health professional after hours or on the weekends.” So the question is, will in-store clinics be a boon or bust for emergency departments?

Now, to be sure, this is not a simple issue, but I’m tired of emergency physicians talking out of both sides of their mouths. For those who denigrate in-store clinics, lets get one thing straight: EPs bitch about overcrowding and here’s someone who wants to do something about it. Do you want people to stay away or don’t you? If they say they take 5% off of the ED, that’s 5% of the workload that is no longer crowding you.

That said, there are some problems that I do see with the in-store clinic model. First, conflict of interest. If the clinic is associated with a CVS pharmacy, does the NP have an undue pressure to prescribe drugs? I’m the ultimate conservative on medication; I think most things don’t need a pill. What is going to be the quality control mechanism in these places? Take the recent studies concerning over-the-counter cough suppressants for children. Who is responsible for being aware of these studies and making these decisions?

Another issue is that what works in Boston may not work in Detroit, where fewer people are going to pay in cash. These clinics probably won’t open up where there’s real overcrowding. They’re going to open up in places where they’ll be profitable, which tend to be less crowded, more suburban regions. 

Finally, lets get real about the impact these visits have on our EDs. Are they really breaking the back of the system? No. Most of these visits are two minute visits. These aren’t your people who need CT scans of the abdomen or five-hour chest pain rule-outs. Their impact on throughput in the ED is miniscule. Once the hospital has paid the docs, rent and utilities, the actual cost to see one more sore throat is minor.

Want an answer? Put your money where your mouth is. If you don’t like these in-store clinics, accommodate them in your emergency department. Have a throughput lane. Just don’t talk out of both sides of your mouth.
 

Comments   

# MD, JD, FACEPDavid Davis 2008-03-11 16:43
I have first-hand experience with this at the Walgreens clinics in St Louis, as a collaborating physician. I review 10% of the records.

Most of the NPs do not push the OTCs, and they take new knowledge fairly well, better than MDs. The recent studies on OTCs and ABX over-Rx are known to them.

They have a very limited scope of practice. Cannot do I&D, for example.

They are cherry-picking the ones with coverage, but do take MA. If our crappy health system funding changes, these clinics will probably go away.

Greg, your last paragraph said it all. Either see these pts in Fast Track without delay, or keep silent in criticism.
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# The NP's tend to do OKAaron 2008-03-13 00:35
I agree, these ARE usually very minor complaints they see. Most of the models that I've looked at have severely limited the scope of practice for the NP and they are very heavy on evidence-based practice for the small number of problems they treat. I would say they definitely prescribe less unnecessary antibiotics than the docs in my community. I had a patient yesterday with viral syndrome. She had been to her Family Practice doctor before a cruise vacation and the doctor prescribed a Z-pack that the patient could take "just in case" she got a cold while she was gone! Well, she took two pills then lost the rest and came in for another Rx. I almost dropped dead.
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# Medical Director, Walgreens Take Care Clinic, 1919 W. Gray, Houston, TXDavid Hoyer, MD FAAEM 2008-03-17 17:16
Kudos to Dr. Henry. Patients don't like going to ERs with minor illnesses, waiting for hours and then getting a big bill for 5 minutes with the doctor. They also don't like calling their PCPs and being told to wait a week to get their sore throat or UTI treated. All of the care at these clinics is based on evidence-based protocols with NO pressure or influence from Walgreens.
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