Fast Care, Good Care?

by Dr. Ann L. Engelland

(January 18, 2007) While standing in line recently for a prescription at the Larchmont CVS I noticed that what used to be a storage space has been re -modeled to become the “MinuteClinic”. I am not sure how to pronounce “minute” and whether it refers to size or time, but I am sure that this new kind of health care delivery has arrived.

With new choices of where and how to purchase one’s medical attention, it behooves us to become better consumers. As a pediatrician I worry about the health of my patients and the potential for fragmentation of care that these “curbside” services might generate. As a teacher of medical students I worry about the future of medicine and the potential for fractured, unsatisfying careers. For all of us, I am concerned that we are heading toward a situation where comprehensive primary care is no longer valued.

MinuteClinic was started in Minneapolis in 2000 by Rick Krieger. When he took his son to the local ER for a throat culture and had to wait and wait, his frustration helped him hatch the idea of easily accessible care for “minor” problems. Mr. Krieger set up his first clinic in a supermarket and he has since expanded them across the country. Most recently, CVS contracted to start these “retail-based clinics (RBC’s)” in Westchester.

The MinuteClinic brochure describes a drop-in clinic staffed by nurse practitioners who will see children and adults aged 18 months and older. It specifies that they will treat a predetermined list of diagnoses which includes ear infections, bronchitis, allergies, ringworm, poison ivy and tick bites. Sort of like a school nurse for the community, you might say. Except that they are also dispensing immunizations and medications.

Although such retail clinics were profiled as one of the brilliant inventions of 2006 by the New York Times in December, my concern about MinuteClinic is that it ignores the fundamental way doctors and patients have always appreciated medicine and healing. Patients seek advice because of a symptom, not because of a diagnosis. They rely on the clinicians who care for them to assess all the possibilities and generate a list of possible diagnoses. The differential diagnosis of “bronchitis” is long and complex and involves skilled history-taking and an examination. Can a MinuteClinic do all this? Or will they diagnose what they know best, what is on the List?

The American Academy of Pediatrics recently issued a policy statement opposing RBCs on the grounds that they run counter to the concept of a “Medical Home” for patients. A medical home can be virtual (if communication between providers is of high quality) or it can be actual (one place where records are kept and providers can provide continuity). Besides being accessible and family-centered, the ideal medical home provides “comprehensive, continuous, coordinated, compassionate, and culturally effective care,” according to the AAP position paper. Dispensing flu shots at the pharmacy checkout counter may be acceptable. But how are we supposed to keep track of the myriad shots a child is now required to receive—27 at my last count-- if they are given willy-nilly at a variety of locations?

According to its website, the nine person “management team” of a MinuteClinic includes only one person with medical credentials. This experiment may seem convenient for patients in the short run, but I fear that in the long run the major beneficiaries will be the owners and perhaps the people who work there rather than the patients/consumers.

The catch phrase in MinuteClinic’s brochure is “Healthcare, simplified.” My worry is that we will get “Healthcare, dumbed down.” If we are good consumers, we will be watchdogs of our own medical care and we will choose wisely among all the new options available. If you use MinuteClinic, be sure you ask them to communicate (fax, phone or email) with your primary provider.

As our whole healthcare system evolves let us remember the value of returning to a “medical home” where we have history, tradition and caring. And if you are lucky enough to feel this way about your medical care, “Have you hugged your doctor today?”

Dr. Engelland has a practice in Mamaroneck devoted to Adolescent Primary Care. She can be reached at 698-5544.

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