One of my recurring bugbears is the steadily-blurring line between patients and customers. The expectation for customers at the end of a transaction is that they be satisfied, and everyone knows the axiom about them always being right. A patient, on the other hand, is supposed to be treated. While I would always hope that, when all is said and done, well-treated patients would consider themselves satisfied as well, sometimes it’s not so tidy, and often patients want things that I don’t think they need. Balancing these competing pressures is one of the most challenging aspects of patient care, at least in my experience.
Perhaps it is no surprise that I am no great fan of so-called “minute clinics,” also known as “retail” or “urgent-care” clinics. I think they are a bad idea for a whole host of reasons.
The first and most obvious reason to avoid them is that they have no access to a patient’s medical record, and thus their medical history. They don’t know what medication allergies a patient has, what medications they’re taking, and what medications may have been tried already for any particular complaint. Now, one might argue that patients should know all of this about themselves and thus be able to inform the providers at a retail clinic about what they need to know. Sadly, patients often don’t know this information about themselves. I can’t tell you how many times I’ve asked a patient if they’re allergic to anything, been told they were not, and then seen in the record that they are actually allergic to the medication I was about the prescribe. Providers who try to deliver care without a reliable medical record run the risk of making avoidable errors.
Partly for the above reason and partly for the reason I’ll get to next, I’ve observed that the care delivered at these clinics is sub-par. I know this is a generalization, and doubtless there are many providers at these clinics who practice good medicine. However, far more often than not the patients who return to my office for follow-up care after having visited one of them have been put on medications they didn’t need (typically antibiotics) for infections they didn’t have. I greet each new prescription for Zithromax (an antibiotic whose spectrum of activity is too broad for it to be used liberally when other, narrower-spectrum antibiotics will do, and the over-use of which is the hallmark of a lazy doctor) with a weary sigh.
Why do these clinics seem to hand out these medications like they were candy? Because to them, patients are customers. Their relationship is wholly transactional, and their goal weighted toward the satisfactory delivery of a requested service. While I have no doubt that providers there have some standard of care their seek to meet, I question whether the context of their patient interactions makes best practices possible. It is much easier and faster to write out the implicitly desired prescription than it is to explain why doing so is not in the patient’s best interests. Some patients will be unhappy with being told they’re not getting a medication, and letting them leave dissatisfied is inconsistent with the mission of a retail clinic.
The dynamic is different for patients at a primary care office. The relationship, at least ideally, is one of mutual respect and trust. At my practice, we have worked very hard to establish a reputation of excellence, and we hope that patients take that into account when we give them advice that may not be what they want to hear. As patients and families come to us over time, they see that we take good care of them, and so even if they leave without what they came in seeking they have invested enough with us to trust that we are making the best clinical decision we can. There is nothing analogous in the setting of a minute clinic.
There are times when you need to see a health care professional early in the morning, or later at night. Have you tried to get an appointment lately when you’re sick? It’s hard! That’s not all. You often have to wait a while.
Almost two thirds of Americans have trouble getting care on nights, weekends, and holidays. You know what? A significant amount of the week is filled with nights, weekends, and holidays. Especially if you don’t want to miss work.
It’s fine to believe that people should try and see the doctor in the office. But if you want that to happen, then you need the office to be available. If retail clinics do a much better job in that respect, you can’t complain when people make use of them. In my example, my kids could be seen at 8AM, before school, without an appointment. That’s useful. If physician offices want that business, they should do the same.
There’s a lot to this, some of which I understand, and some of which gives me pause. My perspective is a little bit skewed, in that in both my current job and my previous I worked for practices that made accessibility a major priority. My current practice has walk-in hours every weekday morning from 7-8, is open until 7 PM every weeknight, has office hours every Saturday morning and we are even available (to a limited extent) on weekends and holidays. I have to agree that waiting a week for an appointment for an acute illness is totally unacceptable (and would be curious to know in comments if many people have had the experience of being made to wait that long for a sick visit).
And yet, even with as much accessibility as we provide, a small number still go to minute clinics because they are momentarily more convenient. I suspect an attitude similar to something Carroll briefly indicates in his post, when he mentions not wanting to miss work for a doctor’s visit. While I grok that nobody wants to miss work… well, maybe sometimes that’s a choice you should make. When I’ve needed legal advice, I’ve had to miss work to visit my lawyer. Lord knows, if you have a plumber who’s willing to work around your work schedule, you’d better hold onto his number like it’s gold. Why would seeing the provider who is most likely to deliver better care a consideration that takes a backseat to convenience?
Obviously, there are times when something just can’t wait (though I’d gently suggest that non-emergent care can almost always wait until morning). I’m not arguing that there’s absolutely no role for acute-care clinics, though I’d generally favor those affiliated with well-regarded medical centers as opposed to retail outlets. But if the option exists to wait a little bit to see the provider who knows you best and who has the best information about you at hand, isn’t that worth prioritizing?