Yes they need guidance of a well trained physician, but they won't always KNOW they need that guidance. I'll give you a for instance. I've gone to the CVS Minute Clinic for simple things like a strep test, because it's quick and convenient, and I didn't want to wait for an appointment with my PCP or to go sit in the ER for an hour. But I'm a doctor and so I wasn't really relying on the NP there to diagnose me -- i already knew I had been exposed to a patient with strep throat and had all the symptoms, I just wanted the confirmatory test and if positive, antibiotics. The dozens of other people I saw signing up in their computerized appointment log may very well have had real pathology, and they were actually relying on the NP working there to get it right. And not only was that NP questionably trained, although very personable, but she has all the incentive in the world to prescribe a Multitude of CVS Prescriptions and products to her patients/customers. It's a huge Conflict of interest, and it's bad medicine. But it's convenient as heck, and to a Huge extent I think that's really what most patients really want -- someone in a White coat who would see them quick, and give them meds that will make them better. It's back to the snake oil salesmen of the turn of the prior century -- there's no ailment that can't be cured by some magic salve. It's also, I suspect, where you go if you see a drug ad on TV and want to try it out without getting bogged down by doctors telling you maybe it's not appropriate. While I'd like to think that the CVS NP knows enough to send people with real pathology to a doctor, I have no good reason to think this is actually the case and I'd be shocked if at least a few people who really needed a good doctor/surgeon didn't get sent home with an armful of CVS products to try first.
But for the 90% of primary care patients who probably would get better on their own over time or with antibiotics, I still think this model pares down the number of patients the primary care doctor gets to see. He loses all the easy office visits where he makes money doing very little. He gets saddled with the complicated patients who fail the easy antibiotics trials at CVS, whose visits tend to be longer and less lucrative. Anyone who thinks -- let the NPs have the easy patients, doctors can take care of the complex ones doesn't understand how reimbursements work. You need to subsidize the complex patients, on whom you dont make money, with the easy ones. If the easy ones get cherry picked away by NPs, you are not going to be able to stay in business.
Law2doc, much respect to you....seriously. I do, however, think that this model will jump up to bite someone in the ass; b/c I doubt if people that want a quick fix for their "easier" problems are really going to give a thorough medical hx? Are the NPs actually gonna insist on taking one. ???? And since they are not really a true, primary care provider, stuff is gonna get missed. I mean geez, for some folks, you can do a quick, once over and pretty much get that they may well be more complex in terms of hx and comorbidities.
Plus, smart people are learning that it's better to be be in a good, reputable system. My example would be say University of Penn medicine. They have worked hard to have systems that share health information, and many of the physicians know each other well. Doesn't mean you can't get another opinion elsewhere. But what it does mean is that when you have a complex patient, w/ a number of comorbid issues, it makes much sense to have a more seamless approach to information sharing and contact. When you run into a problem and don't have this, it is a huge pain--sometimes just as much of a pain as when you want to get a family member transferred out of one system and transferred to another. You have to get a physician that will receive them. It gets so incredibly complicated and stressful. I have been through this 3 times with close relatives. Each time it was beyond time-consuming and stressful, and that was even using any networking/relationship cards with docs. Doing this is so much stickier today than it was in years past.
But you know, these "quickie mart" clinics can do a great disservice in terms of public health; b/c they lack a strong, primary care physician or internist following them or a health network system of support. We shouldn't be encouraging fragmentation of care in order to get more people seen.
One thing the American model of medicine has striven to do, especially in comparison to other health systems, is to go for the highest quality of care/tx. No, that is no always the case,
but patients in our healthcare system, in many cases, have the ability to seek out better quality providers and health systems.
I don't buy this whole deal of having something is better than nothing, necessarily. It undermines the very important nature of primary care medicine and providing sound, optimal care to patients over the lifespan.
Some people go into medicine where they don't want to or have to know their patients long. Even I as a nurse years ago got tired and stressed with having the same medical ICU or medical cardiac ICU patients, many of whom would be left in the units languishing way too long. So the I opted to move into Surgical ICU and Open Heart Recovery, and in most of those cases, we stabilized them and moved them on. Then I did this with pediatrics, and moved back into seeing the benefit of helping people in the long term and optimizing care and emphasizing prevention. It's like I came full circle, having realized that while having surgery is often vital, it doesn't really "cure" the patient in many cases. Often the disease processes that were in placed that caused the need for surgery were still present and needed addressing and sound follow-up and prevention whenever possible.
The NPs at these clinics have no real, long-term vested interest in these patients, for the most part, these "mini-mart clinics" are not set up to be like that. And this is going to, as I said, bite someone in the ass. Give it time. We will live to see it.
In the US, patients generally want quality in care. And in primary care, they want someone that knows them and has a vested interest in their wellbeing. Maybe I am some idiot idealist; but that is what I believe and have noted in my years of practice as lowly RN.
Even in poor, urban settings this has come through. I can show you community health centers in urban areas that are very successful in meeting the needs of patients, particularly those of a chronic nature, and some of them are actually run by NPs. BUT they know their limits and work well with a strong, university hospital system. The have strong social workers and strong community health educators, etc to assist with their needs and help them to move more seamlessly into an out of the university health system as needed.
This is an entirely different model than CVS walk-in clinics. The former meets the needs of the poorer people in the immediate urban setting, who would otherwise neglect their health needs until they got fed up enough to take up space in an ED. The community health center to which I am referring generally has good patient return and follow-up, thus more people get their healthcare needs met on an ongoing basis, and they are well-known by the providers at the center. It's very much based on trust and relationship. The "Quickie Mart" store centers generally are not. There is no real investment in the community.
