[NPInfo] AMNews article-Retail clinic MD supervision

[David Mittman]

What a totally strange interpretation of why an MD is needed, what  
NPs do at retail clinics e.g.. treat "self limiting diseases". Full  
of some strange ideas like observing the NP and determining if this  
is someone you would want giving care????????? Why don't we observe  
the doc and interview them to see if the are taking the job because  
they are afraid of patients, if they are incompetent or maybe see if  
they are someone we would want to be giving us care!!!!!
D



Ask questions before working at retail clinics

Ethics Forum. April 7, 2008.

When should physicians accept employment with in-store clinics?


Scenario: When should physicians accept employment with in-store  
clinics?

A for-profit health care organization employs certified registered  
nurse practitioners to treat common ailments in a clinic housed in a  
retail store and wishes to hire a physician to oversee the operation.  
How can the physician be sure the clinic will deliver quality care  
that meets professional standards?

Response
It appears that rapidly expanding retail-based medical clinics are  
here to stay. These clinics began in national pharmacy outlets, but  
their success has inspired large retail chains such as Wal-Mart to  
place them in stores. Their services appeal greatly to the segment of  
the patient population that values efficiency: They are available to  
patients when their primary care physician has no openings;  
appointments are not needed; waiting time is minimal; most insurance  
is accepted; and co-pays are not much different than for a routine  
visit to a primary care physician.

Discuss on Sermo


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Retail clinics are proliferating because they offer a level of  
convenience that is not available at most primary care physician  
offices in the United States. They are open late at night during the  
week, and on Saturday and Sunday. Their niche is the provision of  
primary, nonemergent, acute care by licensed and certified registered  
nurse practitioners.

CRNPs treat a small number of common, self-limiting ailments,  
including cold viruses, the flu, sore throats, urinary tract  
infections and minor injuries, and offer vaccines and other routine  
preventive care. They do not treat complicated illnesses or offer  
EKGs, lab tests or x-rays. CRNPs do not give treatment advice over  
the phone or call in prescriptions. Other than treatment for UTIs,  
generally no care is provided "below the waist" -- neither routine ob- 
gyn care nor the evaluation and treatment of sexually transmitted  
diseases.

While experienced CRNPs staff the in-store clinics, physician  
oversight also is required, and many doctors find that the  
opportunity to serve in that capacity is worth exploring and  
potentially satisfying.

Operating out of select Walgreens drugstores in Pittsburgh, Take Care  
Health Systems is one of the larger store clinic operators. Each Take  
Care clinic is staffed by three to four CRNPs who provide coverage  
seven days a week, according to Sandra Ryan, chief nurse practitioner  
officer, and Donna White, assistant lead nurse practitioner. Take  
Care CRNPs rely on specific algorithms of care that the company  
developed to treat patients presenting with symptoms of the  
conditions listed above.

Importantly, CRNPs in Pennsylvania may practice independently.  
Physicians are not required to be on-site, supervise care directly or  
review treatment records in real time. They function instead as  
collaborators who oversee the clinic's operation and give real-time  
assistance and backup to the CRNP only when needed.

These physicians (most often board-certified family practitioners,  
since the clinics offer both adult and pediatric services) are  
essential to assure the quality of care and foster the spirit of a  
team-based approach in this new setting. They may supervise up to  
four CRNPs (in Pennsylvania, but this number can vary from state to  
state) by reviewing charts, being available for calls and providing  
help as needed.

Physician collaborators also serve as sources of continuing medical  
education for the nurse practitioners. The physician typically  
reviews about 10% of the charts for quality purposes, noting any  
individual or recurrent problems, and offers appropriate feedback and  
follow-up.

There are a number of ways for a physician to determine whether care  
at the clinic is appropriate, of high quality and professional.  
Before committing to be a physician supervisor:

Visit one of the local clinics and observe its operation. Take note  
of the environment, staffing, adequacy of supplies and overall  
condition of the clinic space. See how it compares to a typical  
physician's office.
Observe the nurse practitioner. With the permission of the patient,  
observe the exam and the treatment offered. Take the opportunity to  
speak with the nurse practitioner about his or her work experience at  
the clinic. Get a sense of whether this is someone you would want  
giving care.
Ask to review a random selection of charts. Review documentation and  
treatment, and compare it to your own office experience. These charts  
should not contain patient names or other identifying information.
Review the treatment algorithms the company uses. Make sure that they  
reflect current guidelines and are easily understood. The algorithms  
also should specify protocols for managing difficult situations and  
triaging challenging cases.
The above tasks are a necessary part of evaluating the quality of  
care the clinic can deliver. If you conclude that adequate controls  
are not in place for the provision of high-quality and professional  
care, I would suggest that you inform the managers of the health  
system so that they know what you find problematic or troublesome.

If you wish to explore involvement further, I encourage you to  
consider the following next steps:

Meet with one of the current physician collaborators at the facility.  
Have a candid conversation about the responsibilities, the required  
oversight and, most importantly, the time commitment.
Review the resumes of CRNPs you would be hired to oversee. You will  
want to see evidence of broad, general experience since CRNPs, to a  
significant degree, work independently. (Take Care CRNPs, for  
example, have four to seven years of experience on average, with an  
additional 10 to 15 years as a registered nurse.)
Review the company's policies on quality control, auditing and chart  
review. Make sure you are satisfied there is a mechanism for managing  
clinical challenges and policies for handling problems with  
individual practitioners, should they arise.
Review your state regulations on the scope of practice of CRNPs. Know  
exactly what CRNPs are allowed to do without your real-time approval  
in the retail-clinic setting. State laws may vary.
With a proper amount of physician collaboration, retail clinics can  
serve a need for patients who have acute, nonemergent, self-limiting  
illness and desire the added convenience of care without waiting for  
it or having to prearrange it.

This kind of care is not inherently unethical or unprofessional, and  
in fact, many primary care physicians already employ CRNPs in a  
similar capacity. Store clinics are doing it more conveniently by  
limiting the types of patients they see and staying open late at  
night and on weekends. Doctors can play an important role in assuring  
that retail-based clinics deliver services that meet or exceed high  
standards of professionalism and quality.

--Scott Miller, MD, board certified internist; chair of the ethics  
committee, Allegheny General Hospital, Pittsburgh; medical editor of  
the monthly "Bulletin" of the Allegheny County Medical Society