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• kafo

  well, I had an family friend seen at one of these clinics- a healthy middle aged gentleman with a complaint of urinary symptoms. He was inappropriately prescribed a 3 day course of antibiotics, no urine culture $sensitivty, UA,PSA, Prostate Exam or additional testing was performed, contemplated, or planned for. The NP was not interested in the family's feedback, who were physicians, except that after extended phone calls she agreed to extend the antibiotic course. Her attitude was dismissive and closed. I am a PA (Yale University) and it is common knowledge, baseline knowledge, that any male with UTI symptoms automatically deserves workup and follow up. Males with UTI symptoms are not to be treated with 3day course of antibiotics, no matter how "strong" the antibiotics are. An integral part of being a non physician provider (or physician) is to know your limits, to have humility no matter your experience, to learn from critque and feedback. Fortunately my family friend has 2 excellent and attentive physicians in his family who will get him the proper evaluation and care he deserves. However, I am concerned what will happen to the next gentleman who presents to this providers, with UTI symptoms without an informed advocate to help them.

  Dec 23, 2009

• Patricia Anderson, FNPbc

  Thank you Dr. Clavreul for your article. There are a lot of truths to what you say. Additionally, what was not mentioned in your article are the tremendous amount of flaws with the retail clinic model and with the lack of sufficient, compassionate supervision from within the model, particularly from the manager of operations for the LA Market of MinuteClinic, Anisha Dua, RN, NP. As a person who interfaces with Dua, I have strong opinions which impact the delivery of health care by way of provider and patient satisfaction. As a seasoned board certified practitioner and doctoral scholar in Public Health Epidemiology, I am employed in the retail health practice in the Los Angeles Market, working directly with the distant management team personally for nearly two years. Though not a new graduate at the time, when I began employment in the system, it was portrayed as you implied in your article. Seemingly, the model was a haven for independent practice. What occurs in these settings, however, is a lack of respect for the skill sets and safety of the practitioners. As you are certainly aware, in 2005, among all industries, greater than 350 victims were in “wage and salary workers”, per State of California data and “eighty seven of those events involved assaults and violent acts”, (State of California Department of Industrial Relations (DIR), 2009). Even more remotely, in 1999, non fatal assaults on health care workers in the US accounted for 43% or approximately 2,700 assaults on people in the health care industry, according to sources. Authors of the Lipscomb, et al., (2002) study noted that frequently workplace violence occurs where “most of the victims work in retail trade” where, generally, persons unknown to the victim commit the violence acts, including workplace homicides. Further, these authors noted that a great majority of workplace accidents occur when the victim and the attacker are in a client – caregiver relationship. The CVS Pharmacy “Minute Clinic”, Walgreen Pharmacy’s “Take Care” and similar retail clinics are poised to be forerunners to address violence in these niche settings. Too often, due to staffing inadequacies, failing peer relationships and a retail business mentality of these health companies, there exists a loss not addressed in your piece. Provisions in the State of California Labor Code (State of California Legislative Counsel, 2009) were enacted as a measure to ratify “protection of public health”. Section 850-856 makes special provisions for employees who “work in any store, dispensary, pharmacy, or laboratory”. Personally, these provisions appear lost in the inefficient MinuteClinic management. Without first-hand knowledge, NP job seekers are not aware of the demands to see 50 - 100 walk in patients, USUALLY with no front or back office assistance during heavy seasonal influenza periods. The ability to triage, input medical billings, provide education, collect necessary supplies, perform safe, sanitary procedures for injections, provide post education and documentation is no simple task - particularly when there are sick patients who do not present for flu shots and angry patients who arrive to find long walk in clinic lines, inoperable kiosks, and low to no medication supplies. In-store marketing, dusting, mopping, retail store bathroom monitoring and other non Master's prepared duties aside, the board certified NPs in retail markets provide catchment services, less like the Advance Practice RN colleagues and more like glorified Medical Assistants. Why do the NPs stay who are not pleased with the management team or retail model? Despite the ability of each provider to leave when they have had enough, or press a panic button to summon the local police department (LAPD) for help (as this NP has needed to do on no less than three occasions) - without management response, the fact remains that there is a sense of NP loyalty to oneself. To provide for one's family after years of continuing education, a pay check and the promise of insurance is a fine carrot to dangle in front of a hungry nurse's nose. Still, when providers are required to contact no less than 10 - 15 peers to cover a shift, even during urgent mid day illnesses, before being allowed to care for our own personal crises; risk being told to "resign if not happy"; and have routine hostility when unable to meet the demands of a National clinic without an adequate staffing pool (in part due to no short call bonus pay), it is no wonder why the NP attrition rate within the retail clinics from where this writer reigns is increasing at a steadfast pace. Truly, there are NPs who find rewards in seeing a limited amount of routine illnesses. Ear infections and lavages, rapid strep screenings, UTI and FLU FLU FLU shots... are limitless. Maintaining the diagnostic and treatment skills for community and chronic diseases including diabetes, hyperlipidemia, hypertension, anemia and sexually transmitted diseases are skills soon lost when practitioners are settled in the 10 - 6 hamster on a wheel, diagnose from a cook book model of retail health - without seeking additional avenues to care for medically challenging clients. References: Lipscomb, J., Silverstein, B., Slavin, T., Cody, E., & Jenkins, L. (2002). Perspectives on Legal Strategies to Prevent Workplace Violence. Journal of Law, Medicine & Ethics, 30(3), 166 State of California Department of Industrial Relations (DIR). (2009). Table 1. Fatal occupational injuries by selected industry, California, All Ownerships, 2005 Retrieved from: http://www.dir.ca.gov/dlsr/Fatal2005Statistics.pdf State of California Legislative Counsel (2009). California Labor Code. Retrieved from: http://www.leginfo.ca.gov/cgi-bin/calawquery?codesection=lab&codebody=&hits=20

  Nov 22, 2009