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He who hesitates is lost

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How should physicians respond to Retail-Based Clinics? Offer something better. Physicians should make change, not watch with fear.

In his latest post, Flea talks about the phenomenon of Retail-Based Clinics (RBC) that are reportedly sprouting up around the country. These clinics are located in retail stores, such as Wal-Mart and Walgreens(I don’t think it is limited to stores beginning with “Wal,” however), and are staffed by Nurse Practitioners. The promise is that for a fair price (in the $50 range), you can be seen quickly (within 20 minutes) and have your problem taken care of. This gives the added bonus for those stores that the patients will be walking around the store while they wait to be seen as well as being far more likely to use their pharmacy after the visit.

The response from the medical community has been predictable. Lead by efforts of the American Association of Family Physicians, the idea of a “medical home” has arisen. A medical home is the “home base” for any given patient which will coordinate and/or deliver the bulk of the patient’s medical care. This is generally considered to be the realm of Family Physicians, Pediatricians, Internists, and to some extent OB/GYN’s. The clear message is that care should be physician driven and physician supervised. This drive has been joined by the American Medical Association, the American Academy of Pediatrics, and the American College of Physicians.

This sounds resonable to me. Why should patients fragment their care and get unsupervised care in a place with no access to their past medical history? Why should these companies be willfully trying to lower the overall quality of medical care?

Because the patients are sick of how doctors run their offices.

The view of the average physician is that patients have the opportunity to see them as long as there are spots on the schedule. Patients are there for the sake of the doctor - and they should be grateful for the good care they can get. It is worth it to wait to get good care, and those who don’t like it can go see another doctor.

Patients are often made to wait for many hours to be seen for even trivial problems. When urgent situations arise, such as a child with a fever or an acute back injury, often the first available appointment is not on the same day, and so the patient is given the choice to wait to be seen, or go to the ER or Prompt Care. Furthermore, even offices with “open access” scheduling which allows more patients to be seen on the same day force the patient through the maze of voice mail, phone menus, and non-medical operators. Oh yes, and you must call during the office hours and not during lunch.

What other industry operates this way? Why should it surprise us that patients are demanding better and entrepreneurs are responding to this need by side-stepping traditional physicians?

We have chosen to take a different approach to this threat. What we have learned is that we create very loyal patients when we respond to their needs. Here is how our practice has innovated to meet the changing needs of our patients:

1. We have a walk-in clinic from 7:30-9:00 AM and from 5:30-7:00 PM Every day. We are also open from 9:00 AM - Noon on Saturdays. These slots are for established patients (with some exceptions) and are triaged by the nurse to make sure it is truly a “quick sick” problem. We do not want to treat fatigue and depression as a walk-in. The rule of thumb is that these visits must be able to be handled in 5 minutes. When a patient tries to add on other chronic problems, we simply respond by saying, “that problem is too important for us to limit it to this 5-minute visit. We need to see you back for a scheduled appointment so it can get the time it deserves.” In 10 years, I have yet to have a patient object. In this situation the physicians rotate and so patients get whoever covers clinic that day.

2. We allow 1 work-in visit each hour to our schedule. These work-ins are also of the 5-minute variety. They can either by from patients walking into the office or calling ahead. In this situation, patients are preferentially scheduled with their regular physician.

3. We use an electronic medical record (and have been on it for the past 10 years) that lets us have quick access to the patients’ records and make assessments. Without our EMR, we would not really be able to do either of the first two items efficiently.

4. We are soon to launch a feature where patients will be able to request appointments and refills online. This will greatly reduce our phone traffic.

5. We are also soon to launch a “fast track,” where the patient can log on to our website and securely fill out their paperwork prior to coming to the office They can check their medications, allergies, update their social history,etc. prior to coming in. They can also fill out questionnaires pertaining to the type of visit they are having (well baby, diabetes recheck, sick visits, etc.) and all that information will go right into the patient’s chart on the EMR. When a patient has done this, the will be brought back to the exam room right away without having to fill out any paperwork. This will allow us to significantly shorten their waiting times while lessening our staff’s workload. Our goal will be to allow patients to be in and out of our office within 30 minutes for a quick visit.

I know that my patients understand it is better to get their care in one place. The problem is, the one place is often very difficult to get in to and so they seek alternatives. Our goal has been to give them the chance to see us without the hassle. This makes it far less likely for them to use the ER, Prompt Care, or Retail Clinic.

Instead of raising our fists in protest, we should take developments like Retail Clinics as a sign that we need to change. It is possible to do so and not compromise the quality of your care. Our office is going to be the first NCQA-Certified offices for the Diabetes Physician Recognition Program east of Atlanta in our state. Our quality numbers are far above the national norm, and patient satisfaction is quite high. I am convinced that we just need to learn to do better than we are doing rather than convince the consumer that we are already doing a good job. We have been able to do this and remain profitable. Our income has risen during a time when most physicians’ incomes are falling.

What’s the point? First, I get very tired of reading doctors whine about the state of things, thinking they are somehow powerless to change it. Yes, you cannot change the entire system, but you can make things better.

Second, I want folks to know what an “average” doctor can do. Yes, I am a geek, and quite intense…oh yes, and a little bit opinionated; but I am still just a private doctor in a small city in the south. This spring I am actually going to give a talk at the Spring ACP conference on the subject of practice innovation. Why? Because I am not scared to try.

Finally, I want to point out that we physicians are here for our patients and not the reverse. We need to not look at patients as the enemy. We need to not defend ourselves from their criticism, we need to listen to it.

Sounds crazy? You can come down and visit our practice and see us doing it.

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from InsureBlog on Thu, 11/30/2006 - 6:32am

My TMBN colleague, Dr Rob Lamberts, has an interesting post on his practice

Comments (5)

#1: Bravo
Submitted by hippocrates on Wed, 11/29/2006 - 7:31am.

Great summary on responding positively and practically.

Operating in a victim mindset is the surest way to get victimized. Too bad many docs slip into this line of thinking, but as Philippa pointed out earlier many just do not like to worry about "business issues".

Kudos Dr. Rob for showing the way.

Submitted by Steve Beller PhD on Wed, 11/29/2006 - 7:44am.

Very nice, Rob! You're putting the patient's needs first, which is what "consumer-centered care" should be.

Steve Beller, PhD

#3: WOW!
Submitted by Vreni Gurd on Wed, 11/29/2006 - 10:18pm.

Now that is great service!  I would like to forward your post to my doctor - except I don't have her email address and I don't believe she has a website ...

Vreni Gurd

Health and Vitality Coach

Submitted by NPs Save Lives (not verified) on Thu, 11/30/2006 - 12:11pm.

Thank you for addressing the issues instead of bashing the Nurse Practitioners who are working in these clinics. We all need to work collaboratively in order to take care of the patient which is what we are here for. Bravo!

Submitted by Naomi on Sat, 12/02/2006 - 10:37pm.

Thank you for the inside look at how your practice works. I'm planning to share your information with my doc, who is part of a "large cattle drive" system. Maybe he can find a way to implement some of your ideas.

I love the idea of doing all the paperwork including the reason for the visit before you arrive. My doc just implemented a paper version of this concept. Good thing I do my own version at home on the compter before I arrive, but so much better to submit it via computer ahead of time.

I wish more docs would share programs that work at improving care and efficiency.

Naomi Giroux M.Ed., RN

Health Educator, Radio Show Host, Author

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