By Dr. Paul Ehrlich
Harvard Health just published an article by Stephanie Watson, Executive Editor of Harvard Women’s Health Watch entitled “More Americans using retail health clinics.” This extension of the “Doc in a box” model springs from shortcomings in the old system of private general practice, which leaves little middle ground between waiting for an appointment with your GP (if you have a family doctor at all) and the emergency room. “The number of visits to such clinics quadrupled from 1.48 million in 2007 to 5.97 million in 2009… and topped 10 million last year.” Convenience and pricing are among the big drivers of the phenomenon.
What got me about this article is that the pharmacy chain Walgreens’ will now help manage and monitor chronic conditions, including asthma. I don’t believe that this necessarily represents the end of civilization as we know it. Walgreens’ Take Care Clinics can help patients do things they could be doing for themselves, but often don’t. If a friendly nurse practitioner or physician’s assistant working on a Saturday afternoon can take a peak flow reading and recommend that a wheezing patient step up dosage of her meds, in accordance with an asthma action plan worked out with an allergist, and gently reinforce the message of compliance, it would be a good thing. If they can provide a refresher in how to use inhalers, that would be great because even allergists often don’t instruct patients adequately.
Watson cites Dr. Ateev Mehrotra, associate professor of medicine at the University of Pittsburgh, lead author of a new study, in pointing out that on some measures of care, patients who went to nurse practitioners did as well as those who went to doctors. She goes on, “In some aspects of care, retail health clinics may actually outperform physician’s offices. ‘Whatever they do is guided by evidence-based protocols,’ says Regina Herzlinger, Nancy R. McPherson Professor of Business Administration at Harvard Business School, and author of Who Killed Health Care? Not only are nurse practitioners required to follow specific care guidelines, but they must also keep meticulous records on the care they’ve provided, she says. ‘They have a record of what they’ve done that’s very detailed.’”
Julie Lambiaso, the PA at my office, is a perfect example of the combination of professionalism and personal touch that can make the difference between sound medical advice and truly effective treatment. She makes our patients healthier and makes me a better doctor. I gained insight into the potential of this model a number of years ago when I started a program called Project E.R.A.S.E., which placed allergists in inner-city schools to work with worst-of-the-worst asthmatics. We weren’t allowed to “treat” the children, but we were able to examine them, coach them and their parents, listen to their stories, and so forth. The results, as we wrote in our book, were dramatic. “Compared to the previous academic year: School absences fell by more than half (128 to 57); Emergency room visits fell by one-quarter (40 to 30); Hospitalizations fell by more than three-quarters (26 to 6).” If Walgreens or Walmart or Target can fill some of the gaps in asthma compliance, fair enough.
Am I obsolete? I’m not worried. As long as the NPs and PAs stick to monitoring and management, they can do a great service. If “competition” makes doctors more attentive to patient needs, that’s also good. I have always taken calls from patients in emergencies through my answering service even when I wasn’t on call. Now I even give my cellphone number out and answer it at all hours. I find that over a period of time, this level of attention helps patients and parents become better at self-management—the calls don’t go on forever. But these retail practitioners shouldn’t be adding or subtracting medications. They should listen to patients sympathetically. Above all, they should use these words frequently: “You’d better call your allergist.” Oh–one more thing: they should buy our book and consult it regularly.
Photo by bridgeandtunnelclub.com