Failure to Communicate

Wife recently had to get treated for an overwhelming sickness that she couldn’t ignore anymore. Almost 2 months had gone by with her having various URI and a constant shortness of breath or tightness in her chest. These feelings were more marked with cold air, exercise, and exposure to cigarette smoke.

Diagnosis? Asthma with complications related to non-treatment.

Easy enough to see.

But she didn’t believe me, as she’s wont to do, and a few times I got upset and would castigate her for complaining. After all, coughing constantly and complaining about feeling tired/ ill when you could get better from an inhaler just began to wear on me (even more is the idea that she didn’t think I was correct – but that’s a different post).

So the other day, after she developed some night sweats, productive cough, fever, and chills I forced her to go and see a physician. Ironically she couldn’t get in that day and instead went to a retail clinic. I wasn’t with her as I had an obligation to get through in order to graduate (more on that in another post) and only found out about her treatment later.

The NP was very nice, from what Wife says, but it was clear to me that she was a little overwhelmed by Wife’s symptoms. She gave her an antibiotic, an inhaler, and cough suppressants stronger than the OTC variety. I didn’t agree with some of what was done – like giving a very strong antibiotic normally reserved for hospitalized patients or those with community acquired pneumonia, or the suggestion that she go to the ER to “maximize her breathing”, but at least something was accomplished. I was glad to hear that the NP took her time to explain things out to Wife and even told her that she felt she was incredibly sick.

What was funny to me, however, was that Wife was told almost the exact same things that I had for months told her about her asthma. She didn’t want to believe she had it and refused to go to a doctor and “waste her money while they guess”. I find it ironic that a lot of what I try to champion in others and get heated about on this blog has not been instilled into Wife. Somewhere she’s lost her faith in medicine, despite being exposed to it more than ever, and doesn’t trust doctors. Gotta work on that.

Taking PCPs Out Back

In a ridiculous turn of events, it appears that Wal-Mart is starting to link their retail clinics with hospitals and other physician offices – in order to have name recognition.

“We have learned that people are willing to receive their health care from the front of a store or the back of a drugstore,” said Dr. John Agwunobi, a medical doctor who is a Wal-Mart senior vice president. “But customers also have said they would rather it be delivered by a trusted name, a local health care practice, a trusted local provider of care.”

Thankfully there are still some people who are actually thinking straight regarding these “trends”:

Medical societies are inclined to be skeptical of the clinics. The American Academy of Pediatrics opposes them, saying they add to fragmentation in the health care system.

The American Academy of Family Physicians and the American Medical Association have set forth principles for clinics to observe, including sending patients’ medical record to their doctors and finding doctors for patients who do not already have them.

It’s a rather interesting read overall, stating that many clinics have yet to even break even and there are a few that have closed down, leaving NPs and patients alike without much to show for it.

What I would like to know is whether people actually think these are the “way of the future” or a “fix to primary care medicine” as often touted. Yes, it increases a patient's ability to get seen that day, but it also increases the amount of interactions, reduces the medical record keeping by spreading it out over many providers, and runs the risk of patients receiving medications that will interact with drugs they're already taking. When I think about how hard it is to just get a hospital to send over the records from a patient's stay or ER visit, I can't even fathom what places like these will do - regardless of their claim to be connected with your doc. I'm not buying.

We keep dumbing down our healthcare delivery systems all for the sake of convenience, reducing costs, and providing more access. The problem is, when you pay peanuts, you get monkeys.

If I were a physician and the hospital or clinic I was considering working for showed this level of concern related to medical care, I’d walk right out the door. They're getting ready to take you out behind the dumpsters and shoot you in the head...just as soon as you're not beneficial.

Oh Dear

Consider this:

This is my local grocery store, where I am waiting in line*, observing a brand new addition – a retail clinic. In a grocery store. WTF?

They call this little shack “The Little Clinic”. Clearly. What makes me laugh though, is the signs in the background stating that this is a “perfect compliment to your primary care provider”. My question, of course, is: How?

How is this complimentary in the least? Do you actually think that the doctor will be informed of the “diagnosis” arrived at by the provider? Neither do I.

What I do know, however, is that the CVS store next door recently opened a retail clinic and was apparently taking too much business away from this store’s pharmacy – located just off camera to the left. I’m sure we’re all much happier knowing that this little shack is taking care of patient complaints.

In case you're interested, the AAFP has a quick tidbit about what these "complimentary" services should actually deliver - to be complimentary. Personally I wonder if this actually happens much at all.

*And yes, I did need chocolate milk. It's quite tasty.

** For more on my thoughts on retail medicine (like you don't already know), please check these posts.

Automatic Automatons - Perfectly Said

I found this great post about the difference between "providers" and physicians. The Happy Hospitalist has said what I could not, because of the vast distance between our training, about why NPs and PAs are cookbook providers while physicians are artists. I couldn't agree more.

Automatic Automatons Part Deux

“Sweeping generalizations should not be made about any [field of medicine]”.

I couldn’t agree more with that statement. The premise to the last post was not to slam nurse practitioners and physician assistants, but rather identify the flaw inherent in the retail clinic model of healthcare reform.

Often these clinics are staffed by younger, less seasoned professionals who are not well supervised and often work within the shadow of the behemoth that employees them. They feel the pressure to move patients, treat them similarly based on error prone algorithms, and give drugs for anything that looks infectious. That is not simple hyperbole, but a fact. I’ve been informed by several people who’ve either worked in or for these types of clinics of these types of pressures and have experienced a similar form of medicine early in my third year of medicine in an office that employed two PAs and 1 NP so that the doctor could manage his “businesses”. The pressures levied on those three providers to get as many people in and out as possible was tremendous. I could understand, as faulty as it was, to give amoxil for a 12 hour case of sore throat.

What scares me is the fact that you are being treated by people with less education than I’m at currently and have to deal with administrative bullying. When I enter the medical field as an intern I will have some autonomy, but leveled with so much restriction and guidance it will make me feel powerless - like a med student again. By it's nature, a residency allows young doctors the chance to improve slowly, while their training and skills are evaluated and redirected as needed by more experienced faculty. They are taught to be brutally critical of their and other's performance as it related to outcomes and current clinical practices.

I don’t feel that someone with three years of post graduate education who receives little to no feedback on their patient performance beyond “move more meat!” can be expected to improve. In fact I feel that these clinics will only dampen the skills these providers have developed in order to get patients in and out more quickly.

Certainly there are physicians out there that are less than admirable about their patient encounters and prescribing practices (since I’ve worked with a few I should know), but I truly and honestly believe that once they completed their education they were far more capable of handling patient’s complaints and evaluating them properly using evidence based medicine than a 3rd year medical student. Because that’s honestly what you’re getting with a retail-clinic provider fresh out of school.

Automatic Automatons

There are some things in medicine that irk me beyond rational thought. These quick, “urgent care” clinics are definitely a topic that incites rage and hatred in me. They are, to a word, pathetic. Pathetic excuses for healthcare, pathetically trained or motivated people caring for patients, and pathetic attempts to “fix” the healthcare system in the US.

Part of the reason they are such a poor medical facility is due to the people treating most of the patients. NPs and PAs, free from a great deal of medical supervision, are often found handing out erroneous and falsified diagnoses - only to then treat everything with antibiotics or other unnecessary medications. An example of this irresponsible behavior is a story I heard recently encompassing most of these qualities:

A mother whose adult son had a sore throat and was too busy to get it evaluated, went to an urgent care clinic knowing that she could fake his symptoms and receive a Z-pack. This was done because her doctor wouldn’t normally give medicines unless specific tests were positive. She, of course, received the antibiotics (despite having ANY illness) and proceeded to give it to her adult son.

This kind of malpractice (for it really is irresponsible medicine) only increases the drug resistant bacteria that we’re seeing and encourages patients to demand drugs they don’t need. What’s worse is the notion that medicine is like a cookbook and all symptoms should be treated the exact same, regardless of testing and patient profiles.

For all the complaining patients do about their long waits, the doctor’s refusal to give them some drug they read or heard about, or their increasing dubious belief that they are as able to diagnose themselves as effectively as their PCP these clinics are not the answer.

Consider the story above: what if the antibiotics given reacted badly with another medication, or had to be altered due to liver or renal failure, or caused a severe allergic reaction? All things that a PCP would most likely catch through charting or questioning but would characteristically be missed by a NP or PA trying to get as many people in and out of their fast-food-medicine chain as possible.

“What the hell do I care about giving medicines without proper test results? It’s a pain in the ass to do it any other way and it takes up valuable time. That's not what Walmart/ Walgreen's/ Target is paying me for”.

Instead of responsible and smart medicine, what you have are people who will not use medical evidence to properly treat patients and essentially run a medical McDonald’s – have it your way. Sore throat? STREP! Neck hurts? LORTAB! Sniffles? SINUSITIS! To add to this obvious disparity is the fact that these clinics are often owned by corporations who want people to be sick and have to go to their pharmacies. It's not rocket science to see how there's a conflict of interest.

Now I don’t think NPs, PAs, and CRNAs are entirely bad - quite the opposite. They are important in that their job role allows overworked physicians time to focus on the more complicated patients and running their practice while more minor ailments and procedures are analyzed and treated - after a quick review with the physician. However what I do find absurd is the idea that they can take care of patients without strict physician guidance as often occurs in these retail medical centers. Regardless of their time, they haven’t received the training requisite in order to differentiate between disease processes that appear very similar, nor is it expected.

If you still haven't jumped on the bandwagon, realize this: a nurse is trained in a very different way than a physician. They are not expected to figure out the pathophysiologic basis of a disease, the subtle interactions between comorbidities, the ever increasing need to be smarter about treating seemingly simple infections, and the evidence that alters treatment regimens amongst patients. Their training is based on recognizing a defect or a problem, alerting the appropriate people, and following a procedure or "order". If a patient has X, then give Y. If this happens, call the house officer or the patient’s doctor for direction. Adding a couple of years to the training does not inculcate the need to think beyond this automatic process, no matter how much you “shadow” a physician.

Experience certainly lends itself to making people think they know more than they really do. Twenty years in the ICU will definitely make you appear smarter than the intern or second year resident rotating through that service, but only for a brief period of time. Of course you’re going to know more about vent settings, how to respond to codes, etc. than a newly minted MD; but a seasoned physician, who has spent some of their time in the critical care arena will run circles around you - no matter how long you've worked there.

The physician trains in a wide array of specialties for which they are expected to understand a great deal of complexities, is responsible for the outcomes of their patients, and understands more about the overall process leading up to and currently occurring in that patient than an NP, PA, or tenured nurse could hope. A few decades of experience does not overcome the difference in education. A physician with twenty years including residency will always come out on top.

Residency is designed towards this goal. It is the resident’s training, adding on top of the knowledge procured through four intense years of medical school, that makes a physician more than just a “medical mechanic”. Performing a task a million times is not the same as medical knowledge. It is habit, and, as often seen when new policies are passed, is often hard to break.

Urgent care clinics are not the answer to the healthcare crisis. If we expect to take care of patients in better ways, to reduce drug resistant bacteria like the current MRSA “epidemic”, and have more advantagous outcomes we must realize that physicians are not replaceable by technicians. The years of training that doctors receive and the strict environment that they receive their education in makes a physician far more capable of truly evaluating patients. What you are receiving when you see a physician is a decade or more of increasingly detailed knowledge and arduous training that enables them to treat people effectively. Four to six years of training is not even close.