Dream job for doctors

[Rich_by_the_Bay]

Just heard that a local Walmart has opened a walk-in clinic. My colleague inquired just for fun as she was buying some made-in-America goods. Here's the deal:

• They take all comers and all insurance, $15 per visit. This is lower than most deductibles, so basically it's a cash deal
• They see up to 100 patients per day - figure a 14 hour day or about 7 minutes per patient given minimal break time
• Don't prescribed any controlled substances
• She wasn't sure but thinks there was a discount if you filled your script at the WallyWorld pharmacy

A few local grocery chains are doing something similar but with nurses or nurse practitioners.

 

[brewer12345]

Sounds unpleasant for the clinician, no? I mean, you'd be going through a pack of Depends a week.

 

[wabmester]

I wonder what would happen in this country if the barrier for MDs were lowered, and access increased. I can't imagine the net result being worse than what we have today. Many more people would have access to health care, most people would be less reluctant to seek care, and the hot-shot specialists would still have their high-paying gigs for when they were (rarely) needed.

 

[Rich_by_the_Bay]

Sounds unpleasant for the clinician, no? I mean, you'd be going through a pack of Depends a week.

It would be the job from hell.

When I hit my stride in the outpatient world (I'm an internist), I saw about 15-17 patients a day and felt rushed at that. But even a family practitioner sees 30 or so a day. 60-100? Hello-take this-goodbye-repeat. Malpractice waiting to happen, IMHO.

Of course you do have that pleasant and classy ambience to practice in.

 

[Rich_by_the_Bay]

I wonder what would happen in this country if the barrier for MDs were lowered, and access increased. I can't imagine the net result being worse than what we have today. Many more people would have access to health care, most people would be less reluctant to seek care, and the hot-shot specialists would still have their high-paying gigs for when they were (rarely) needed.

Sounds good to me.

Just not 6.5 minute visits at Walmart, thanks.

 

[wabmester]

Just not 6.5 minute visits at Walmart, thanks.

Hmm, an immediate 6.5 minutes at Walmart or 3 hours to wait for my 6.5 minutes at my local emergency room? Tough call.

 

[Rich_by_the_Bay]

Hmm, an immediate 6.5 minutes at Walmart or 3 hours to wait for my 6.5 minutes at my local emergency room? Tough call.

Not if you have a real emergency. Shouldn't be there for any other reason - that's why we have 3 hour waits.

 

[wabmester]

Not if you have a real emergency. Shouldn't be there for any other reason - that's why we have 3 hour waits.

Exactly. One of the beneficial side-effects of increased low-cost access should be that ER's start getting used for emergencies again.

 

[Rich_by_the_Bay]

I am not aware of any good studies to validate or disprove the point, but the risk of overlooked and dangerous diagnoses might vary indirectly with the time/visit. I would speculate that it's flattens out quickly at about the 12-15 minute mark or so for urgent care (that is, if you spend 12 or 15 minutes you will probably pick up everything you would if you spent 30 minutes). Here are some classic masqueraders:

Heart attack posing as indigestion
Meningitis posing as flu
Stroke posing as an arm or leg problem
Appendicitis posing as stomach flu
Intracranial bleed posing as a migraine
Heart Failure posing as asthma or allergy flare
Hypothyroidism posing as depression
Heart attack posing as a lower tooth or jaw problem
Aortic aneurysm posing as a kidney stone
Impending stroke posing as an eye problem (loss or distortion of vision)
Gout posing as a knee or ankle injury
Infected joint (very serious) posing as gout
Pulmonary embolism posing as asthma/allergies/anxiety reaction
Deep blood clot (thrombosis) posing as infected leg, calf injury

These are just a few things that jump to mind and which I have seen repeatedly. Must be hundreds more. Of course many symptoms have a psychophysiologic component, and this requires time and an actual relationship to handle properly and safely. You just have to take the time to ask a few questions and, most importanly, shut up and listen to your patient. They will usually tell you what they have if you listen well enough.

Not sure that assembly line approach is best for any of these. For other issues (need a suture, know you sprained your ankle, got a minor skin infection) I guess it's OK. Unlike that $12.99 toaster oven you bought just before your visit, you can't just come back for a refund if things don't work out quite right.

Caveat emptor, big time.

 

[justin]

Well, I think in many cases it will work well. Wait an hour at my regular doc for a 6.5 minute visit with the MD or get walk up service at walmart for a 6.5 minute visit w/ the MD. Both MD's are gonna say the same thing in response to my 1 y.o. daughter's fever and vomiting - checked ears and throat - not bacterial, probably viral. Give her tylenol, fluids and rest. Wait it out and come back tomorrow if things don't get better.

(I just agreed to go to the Dr. to get my wife to stop bugging me about our OMG sick baby with a 100 degree fever).

If I made $6/hr at walmart and had a sick baby, I'd certainly appreciate the $15 6.5 minute visit to say "all is fine" more than spending an hour waiting in line at a primary care physician and paying $150 out of pocket (my charge yesterday for the "6.5" minute visit).

It would be nice if it were different, but thems the facts for those at the bottom of the medical care ladder (as I see it). Many of the poorest folks just don't go to doctors when they maybe should. If the cost was $15 instead of $100-$150 and it was a quick process that could be done after working hours, many more would seek medical attention. What if these WM clinics can correctly diagnose 10% of these serious cases masquerading as regular ailments for patients who otherwise would have waited to seek medical attention until it really was an immediate life-threatening emergency?

A big threshold issue that I face as an occasional medical consumer is "when do I need to see a doctor?" If I can resolve that for $15 and a 6.5 minute visit at Walmart while I'm getting my beer, flip flops and oil filters, great. If the doctor tells me "go see a real doctor for a more thorough exam because this is serious", great.

 

[wabmester]

Yeah, the issue isn't low-quality care vs high-quality care.   It's care vs no care for a lot of folks.   Or a short wait vs a long wait for the same quality of care for others.

And I have no idea what office visit stats look like, but I'm guessing that the vast majority of them end up with some boiler-plate treatment.   When I'm pretty sure that I just ate some bad shell fish or sprained my ankle, I'd have no problem going to Walmart for a boiler-plate fix.

 

[sgeeeee]

I wonder what would happen in this country if the barrier for MDs were lowered . . .

You've been brainwashed by the AMA. Who says they would have to lower barriers. Who your daddy is and not your capabilities or motivation has way too much to do with who gets into many med schools. Med schools turn away plenty of applicants with equivalent or better qualifications to those they accept every year.

 

[justin]

Yeah, the issue isn't low-quality care vs high-quality care. It's care vs no care for a lot of folks. Or a short wait vs a long wait for the same quality of care for others.

And I have no idea what office visit stats look like, but I'm guessing that the vast majority of them end up with some boiler-plate treatment. When I'm pretty sure that I just ate some bad shell fish or sprained my ankle, I'd have no problem going to Walmart for a boiler-plate fix.

Or "Dr., can you verify that I have strep throat like I had two years ago, and write me an antibiotic prescription"

or "Dr., I have a rash on my torso that looks just like the ringworm that I had two years ago. I've tried OTC remedies for the last 2 weeks to no avail. Prescription lamisil knocked that right out last time with no adverse side effects. Can you write me a prescription"

or "My kid isn't pooping. What should I give him and at what point do I need to come back here or go to a hospital?"

My guess is they'll have it staffed with nurses and/or nurse practitioners in addition to MD's. As long as at least one staff person can write a rx.

I personally kind of like having my regular primary care physician since they are on call 24-7 and can help me answer the threshold "when do I need to come in and see a doctor/go to the emergency room" questions for free. But there are definitely times I'd like to go to the walmart clinic for some things.

I'm thinking flu shots and immunizations can also be conveniently and cost-effectively obtained through this type of facility.

As to working in this environment, it does sound hectic.

 

[Rich_by_the_Bay]

Just to play devil's advocate...

Or "Dr., can you verify that I have strep throat like I had two years ago, and write me an antibiotic prescription"

90% of sore throats are not strep and will not respond to antibiotics which have a 3-7% incidence of side-effects (and cost). Patients cannot tell viral from strep sore throats reliably. Educate and explain why no antibiotic, at least without a culture... there goes 5 of your 6.5 minutes. The other 5 is listening to why the patient KNOWs he needs a Z-pack and all but call you a quack. Then document the whole thing in the chart (the old 'sore throat/strep/penicillin is not longer adequate for documentation). And by the way, it would be much quicker for me to just write a script for antibiotics, just wrong 90% of the time.

or "Dr., I have a rash on my torso that looks just like the ringworm that I had two years ago. I've tried OTC remedies for the last 2 weeks to no avail. Prescription lamisil knocked that right out last time with no adverse side effects. Can you write me a prescription"

Or is it Lyme Disease which can look very similar? At least do a 3 minute history about possible wood tick exposure, joint pain, do a quick 3 minute exam. Last year had a patient much like that, turned out to have skin lymphoma (mycosis fungoides). Something looked funny about it, didn't respond to creams, scraping showed no fungus, and a biopsy was done.

or "My kid isn't pooping. What should I give him and at what point do I need to come back here or go to a hospital?"

Or is it an intussusception (buckled segment of intestine)? Might pay to do a careful exam, and take 3-5 minutes to counsel Mom and Dad about things to look for, diet. Of course, that one in 500 who ends up rushed to the hospital for surgery or worse who you did NOT examine (and carefully document that exam)... not so good. Seeing 100 pts a day it wouldn't take too long - probably won't be you, but...

My point is that no matter how obvious and simple it may seem to the patient, your doctor owes it to you not to overtest, but at least to be a little thoughtful and cautious. We are the ones who see things when they don't go well. Young, generally healthy patients are vulnerable to immortality assumptions. Experienced docs know otherwise.

I personally kind of like having my regular primary care physician since they are on call 24-7 and can help me answer the threshold "when do I need to come in and see a doctor/go to the emergency room" questions for free. But there are definitely times I'd like to go to the walmart clinic for some things.

Exactly. If I know you a little, have seen you, know that you are not a panic-button type patient (or know that you are, for that matter) I can help you make much better decisions.

So, as always, two or more sides to every story. Hope this helps you understand another perspective.

 

[justin]

So, as always, two or more sides to every story. Hope this helps you understand another perspective.

I can't argue with what you've stated (you're the doc after all!). But the reason I like the idea of the WM clinic is it creates availability of medical services to underserved populations. Lots of folks are poor and/or don't have cars (but can get to walmart for their weekly shopping trip) and/or fear getting fired if they take off from their 9-5 jobs to visit a regular doctor during office hours.

My in-laws are or were in some of those categories. Even after they got BCBS insurance, they still used urgent care facilities or the ER for primary care. I kept telling them it would be cheaper, easier, and they'd get better medical care if they picked a primary care physician and stuck with him/her. Then they could get appointments, ask clinical questions over the phone, etc.

I'm going on the "some medicine is better than no medicine" theory.

Wonder if the WM clinic will let you pay a variable amount for more time with the doc? $30 for 13 minutes?

 

[macdaddy]

"You've been brainwashed by the AMA.  Who says they would have to lower barriers.  Who your daddy is and not your capabilities or motivation has way too much to do with who gets into many med schools.  Med schools turn away plenty of applicants with equivalent or better qualifications to those they accept every year."

Correct me if I am wrong, but I believe the overall admissions rate to medical school is about 45-50%, and this includes re-applicants (people who have applied more than once).  How much can you really raise this before you start to let in people who shouldn't be doctors?  Should the admission rate to medical school be 75%?  At what point do you start to admit people who will just fail out of med school anyway (unless you dumb down the curriculum)?  I know people who applied and who were rejected and who honestly should not be allowed to become physicians, because they just don't have the mental acuity to practice (and the rejection probably saved most of them from going into debt and then failing out of medical school anyway).

Information on the lifestyle of most docs now is starting to filter down to colleges and it is having an effect on people's attitudes toward pre med studies.  Who wants to spend 8 grueling years and go 100k or more into debt to end up making 150k (and be continually at risk in lawsuits)?  Smart kids can make that kind of money in a lot of other fields with no call or liability.  Adjusted for increases in total enrollment, the number of people applying is down. I know specialists who pull down 400k to 1 million a year but I also know that their salaries could be cut by 80% by a single medicare revision bill, and likely will be cut by some amount as budget pressures mount.

Besides which, anyone who wants to go to med school can attend one of the Caribbean schools, land a (non competitive) residency in the US, and then be a fully licensed and practicing MD.  From this angle there is hardly any barrier of entry at all.  Yeah it's expensive - but many US private med schools are around the same cost.  And as far as your parents helping you get into med school... maybe if your parents are in academic medicine or work at the medical school... but those doctors in private practice like 90% of them, it doesn't help much at all.

Most likely in your old age you will be taken care of by nurses and maybe by foreign medical graduates (doctors from another country who came here to make some $$$).  When I was in college, the only docs the university health service would hire were foreign guys from eastern europe, because I guess they were very cheap.  Unless things change that's going to be the future for a lot of people.

 

[Rich_by_the_Bay]

But the reason I like the idea of the WM clinic is it creates availability of medical services to underserved populations. Lots of folks are poor and/or don't have cars (but can get to walmart for their weekly shopping trip) and/or fear getting fired if they take off from their 9-5 jobs to visit a regular doctor during office hours.

You're quite right - the system is deeply broken at many, many levels. It will be challenging to maintain at least decent quality as we worm our way out of the current mess. It's not the Walmart issue here, it's the doc-in-a-box no-time-to-think-or-talk piece that concerns me.

My feeling is that once some type of national health system casts a broad safety net for EVERYONE, then we can fine tune the best way to guard quality, efficiency, and accessibility.

Interesting thread, like 3 blind men and the elephant each "seeing" only the part they are closest to.

 

[justin]

Yep. If the 499 out of 500 folks that come in with symptoms indicating a cheap/quick fix get the correct treatment for $15/pop, that's a good outcome for them. The person that is mistreated by the WM clinic is the guy that comes in with the "wolf in sheep's clothing" symptoms that end up being misdiagnosed and delay in treatment worsens his condition.

Of course there's a good chance that guy would have "toughed it out" until he had to go to the ER anyway if he's a WM clinic patient.

 

[SteveR]

...Interesting thread, like 3 blind men and the elephant each "seeing" only the part they are closest to.

What a setup.....and no I am not going to take it.  

IMHO...
There is a need for Doc in a Box.  
I have seen way too many incidents where a person with few means will not seek out medical attention for a condition until it becomes critical.  The $$ and time spent to save this person for a perhaps unnecessary condition (it it had been treated sooner) have to be huge.  

There are times when we just don't need a personal relationship with a practitioner...we just need to have a bone set, blood tests taken, Rx given or reassurance that we are not going to die in the next few minutes.  

Emergency Rooms have become clinics for the poor.  True emergency conditions are rare at most hospitals.  Trauma centers take the worst of the worst and the rest end up in the ER to sit and wait their turn while the cuts, knife wounds, shotgun wounds, drug overdoses and heart attackes are being taken care of.  Meanwhile rooms are filled with sore thoats, coughs, drug addicts looking for pain meds, and a hundred other folks looking for medical care that could be addressed in a walk in clinic if they only had the $$ to pay for it.  It is far easier to wait for treatment in a county supported hospital for free services.  A $15 Doc in a Box might help ease some of this congestion and waste.  It might save a few lives along the way through early diagnois and treatment of conditions before they turn critical.

Not saying what part of the elephant I am describing.  

 

[sgeeeee]

Correct me if I am wrong, but I believe the overall admissions rate to medical school is about 45-50%, and this includes re-applicants (people who have applied more than once).  How much can you really raise this before you start to let in people who shouldn't be doctors?   . . .

First, you seem to assume that fewer than half the people who apply for med school are actually qualified.  What do you base this opinion on?  It's not like the people who apply to med school are a random selection of the population.  Without some sort of data on the applicants and their success rates in life after the decision, I have no reason to believe that any significant number of them are not qualified.

Second, you seem to assume that the selection process correctly ranks the applicants in order of their potential to become good doctors.  As someone who has been involved in university graduate student admissions processes, I can assure you that this is not true.  

Third, the reason the doctors lifestyle is as hectic as it is relates directly to the stranglehold the AMA has on numbers of doctors through the admissions process.

Doctors and the AMA have convinced many Americans that practicing medicine is the most difficult endeavor one can undertake -- that only the greatest minds can even begin to pursue it.  It's just not true.  Once you get past the vocuabulary, most of medicine is a lot like auto repair.  

 

[sgeeeee]

Yep.  If the 499 out of 500 folks that come in with symptoms indicating a cheap/quick fix get the correct treatment for $15/pop, that's a good outcome for them.  The person that is mistreated by the WM clinic is the guy that comes in with the "wolf in sheep's clothing" symptoms that end up being misdiagnosed and delay in treatment worsens his condition. 

Of course there's a good chance that guy would have "toughed it out" until he had to go to the ER anyway if he's a WM clinic patient.

There's also a good chance that his family doctor would have made the same mistake.

 

[REWahoo]

Once you get past the vocuabulary, most of medicine is a lot like auto repair.

Hmmm. That might explain why my GP was mumbling under his breath about how much he disliked "...having to work on a tranny."

 

[Rich_by_the_Bay]

What a setup.....and no I am not going to take it.

There's hope - the topic is still young.

You're right about Emergency Rooms, BTW. They have become the primary care provider of last resort. Not a pretty sight.

 

[Brat]

A better balance between need and skill set would be to use Nurse Practioners (who in many states can write most scripts) with a longer appointment time.  The NP can take care of common illnesses/injuries and can ID potential serious situations for an MD.  For $15-$20/visit is well worth it from a public health standpoint. 

I agree that some serious conditions could be missed, but most of these folks wouldn't have sought health care until late in any case.  In those communities with this service maybe patients who are seeing an MD could get a discount if they are there as a result of NP referral (bring along a note from the NP with concerns).  Tiered care can be a financial and health life-saver.

 

[Dreamer]

I was told about my doctor by a co-worker and friend. She told me how good she was and how much she cared. I live in a university town with 2 hospitals close by and many doctors much closer where my doctor's office is located. I like my doctor so much because she takes the time to listen to me and asks me questions. She will ask me what is going on in my life and she expects an answer. She knows more about my family and myself than all of my previous doctors put together. I will keep driving the distance to see her and I will wait patiently in the waiting room for her.

I would not want to be the last patient that the WM doctor sees on a Friday afternoon after seeing so many patients all week. I would be afraid of Dr. burnout by that time.

Also, I am not sure how many low income patients would go to WM and pay $15.00 vs. not paying anything at the ER. If you are truly poor, then $15.00 can be a hard hit to a very strict budget.

Dreamer