In The Atlantic, Richard Gunderman, MD, PhD, has delivered “The Case Against Drugstore Clinics“. It is a weak case. Let’s take his strongest argument first:
A woman with a sore throat went to a retail clinic and received a prescription for antibiotics. After a few days, she hadn’t gotten better, so she went to her family physician. The physician determined that the sore throat was probably due to a viral infection. He also, however, talked to her about her overall health and life. This conversation led to a previously unsuspected diagnosis of clinical depression. The patient is now in treatment and doing much better.
A case like this illuminates three important differences between the retail clinic and the physician’s office. First, the retail clinic prescribed an antibiotic, but in the physician’s judgment the infection was not bacterial. Overusing antibiotics can promote the development of antibiotic-resistant strains of bacteria. Second, the minute clinic focused exclusively on the sore throat. And third, the physician’s more comprehensive evaluation led to a diagnosis with important implications for the patient’s overall, long-term health.
Dr. Gunderman’s implicit assumption is that if the retail clinic were outlawed, the patient would have gone to her doctor first. However, there is a reason she did not go to the doctor first: The doctor’s hours were inconvenient; the patient could not get an appointment; or the physician’s fee was too high for such an apparently simple problem. Without the option of a retail clinic, the patient might not have been treated quickly at all, and when she did finally go to her physician he would not have known that the antibiotic had not worked. Dr. Gunderman implies that overprescribing antibiotics is a problem unique to retail clinics. On the contrary, it is a longstanding practice of U.S. physicians, confirmed by research published just last year.
It gets worse: Dr. Gunderman describes a clear benefit of retail clinics as a drawback:
One is the fact that they tend to siphon away many of the simpler, quick-to-treat conditions from physicians’ offices and hospitals — these common problems help keep costs down and keep hospitals in business. If retail clinics handle a growing percentage of the relatively straightforward cases, doctor’s offices and other facilities that offer more complex care will find their average patient becoming more complex, driving up their costs even further.
It is hard to over emphasize how wrong, wrong, wrong this accusation is. The “too big to fail” nature of general hospitals is one reason why they are so inefficient: They do not specialize. This is a major reason why costs are so opaque in U.S. health care. In a functioning market, no enterprise would try to mix easy and complex cases in order to average down its costs. An operation that specialized in high cost procedures would bring those costs down, rather than disguise them by cross-subsidizing from low-cost procedures. We see increased specialization in the practice of medicine itself. The family physician described above, who diagnosed his patient’s cough and depression, likely referred her to a psychiatrist. If she had a tumor in her brain, he would not have performed surgery. By Dr. Gunderman’s logic, neurosurgeons should spend much of their time in low-cost family practice, in order to “keep costs down” when they do a brain operation every month or two.
Few things would be better for U.S. health care than physicians forming collaborative relationships with retail clinics in their communities, in order to improve continuity of care. However, this relies on identifying and breaking down regulatory barriers, not professional turf protection.