Stanley Feld M.D., FACP, MACE Menu


Look What Happens When You Are Not Looking. Part 1

Stanley Feld M.D.,FACP,MACE

I believe in-store clinics are a bad idea and they will fail. If successful these clinics can potentially put family practitioners out of business. If they are marginal, they will put a reasonable dent in the primary care physician’s ability to make a living. It is presently difficult for family practitioners to make a decent living. The development of in-store clinics is the result of the difficulties patients are having with affordable access to medical care. If patients have to go to the emergency room of a hospital, wait three hours to be seen, and incur a large bill for a simple illness the healthcare system is not being responsive to the patients’ needs. Convenient Care Clinics’ attraction to patients is they help them avoid these barriers to care.

The growth of these in-store clinics is the result of the primary care physicians’ (PCPs’) inability to set up their medical practices to match the needs and schedules of the hectic life of patients in America today. The blame should not only fall on the PCP. The blame should also fall on organized medicine’s inability to recognize and respond to the needs of the PCPs’ and the practicing physicians’ patients. Organized medicine should be developing programs to teach PCPs how to respond to the changing needs of patients’. If medical practices do not respond to the needs of their patients, someone will.

A problem with the in-store clinics is they are run by nurse practitioners or physician assistants. They are not under the direct supervision of physicians. For years, physicians have fought to prevent physician extenders from practicing medicine on their own for the protection of patients. Some in-store clinics will have a physician sign off on the medical care provided. However, the physicians will not have had contact with the patient or examined the patient. Most of the time the in-store clinics can get away with this level of care. This type of care cannot be defined as quality medical care. Hopefully the nurse practitioner or physician assistant will recognize a really sick patient. Hopefully, when they do they will send the patient to the nearest emergency room.

I believe the in-store clinics will have a difficult time achieving positive cash flow unless they raise their prices or do more in-store procedures. The financial experience of hospitals that opened DOC in the Boxes to feed their hospitals was disastrous. I predicted a decade ago that it will only be a matter of time before the hospital DOC in the Boxes would go out of business. Many physicians who started these clinics did well monetarily when they sold their DOC in the Boxes to hospital systems. It might be that the pharmacies (CVS, Target, Walgreens, and Wal-Mart) are hoping to make money when the patients are in the stores. Rite-Aid has already closed their in-store clinics in Portland Oregon.

In October 2006 a trade association for these in-store clinics was founded to lobby for insurance payments and other interests. The Convenient Care Association is a nonprofit organization representing health care facilities that provide routine, non-emergency services to walk-in patients at pharmacies.

The goal of the association is to help the in-store clinic learn to profit from acute convenient medical care. The CCA is an association of convenient care clinics that provide accessible, affordable, quality health care throughout the United States. Convenient Care Clinics (CCCs) are being launched across the country to help provide care to meet the basic health needs of the public. These health care clinics, located in convenient locations accessible to the public, are primarily staffed by advanced practice nurses, including nurse practitioners (NPs) and clinical nurse specialists (CNS). They may also be staffed by physician assistants (PAs), and/or physicians (MD or DO). CCA states; “Health care driven by the needs of the patient is at the heart and soul of the Convenient Care movement. “

It looks like the CCA has captured the high road for sound bites. The statement that healthcare is driven by the needs of the patient is at the heart and soul of the convenient care movement is a very powerful statement. It assumes that medical practices have failed. Their statement is in contrast to the public’s perception of non user friendly medical professional clinics.

I have recently received several comments from patients who were examined and blood tested in their physician’s office. The results of the examinations were called to the patients by the physician nurses. The nurses told the patients the results and physicians’ recommendations for specific treatments. One person asked to speak to the physician. She was told she had to make another appointment with the physician. The recommendation was to start a statin. The patient was afraid of the side effects of the statin. The nurse was going to call in the prescription. The writer stated “ so much for your emphasis in your blog has been on the importance of the patient physician relationship.”
“This encounter does not speak well for the patient physician relationship.” I must say the patient was correct. My hope is this is an infrequent occurrence.


You will notice the in store clinics are run by business people and corporations. They are not run by physicians. The primary goal is to make money. The vehicle is providing care that the primary care physician should be delivering.

The AMA in its June meeting passed a policy resolution concerning in store clinics:
“With quick clinics opening in chain stores across America staffed by nurse practitioners and physician assistants, the AMA House of Delegates made clear during the Association’s Annual Meeting that, while it’s not against the facilities in principle, it believes they are no substitute for a long-term relationship with a doctor.”

If the consumer’s clinical experience with the medical profession is negative one and CCA publicizes that its health care is driven by the needs of the patient and those needs is at the heart and soul at the in-store clinics, and you are a patient in need of convenient care, which would you choose?

If CCA’s claims were true, the answer to the question is obvious. CCA sponsored by the corporations listed is in the midst of a huge public relations campaign and media blitz to capture the hearts and minds of the public. CCA’s campaign is clever and might be extremely effective. Everyone loves the underdog, the David who is going to slay the Goliath (the AMA). CCA’s sound bites are perfect for our sound bite society. It looks as if CCA has caught the AMA flatfooted. The AMA’s response has seemed anemic so far.

  • Stephanie

    I appreciate that your blog covers all angles of this cuurent trend in healthcare in the US. I personally have to say that the “Doc in a Box” clinics have been a godsend in my experiences. I am an educated business woman, mother of a 3 year old child and a wife. All of us have insurance coverage and a primary care doctor that I have been going to since I was 18 years old (I am now 32). Within the last couple of years it has been extremely hard to get appointments within 2 weeks of a call…and if it’s an emergency (when your child is screaming due to an earache, believe me it’s an emergency) I get the old “then you should go to the emergency room” statement from the attendants at thier offices. When I DO get in to see her, I wait over an hour even if I have an appointment, and spend 90% of the time there with a NP anyway…I see my doctor for a whole 5 minutes. When you work 8 hours a day and run a household, time is very valuable. I have been able to visit The Little Clinic on a Friday night for my childs fever, sat with the NP who was extremely thorough with us, and had a prescription in my hands within a half hour and didn’t even need to make an appointment. She also made it a point to advise me to go to my doctor when I could get in to assure that the problem was resolved with my child. I understand your perspective as a MD, but the medical community has not addressed these issues which are rampant in every state and with most doctors, therefore leaving the door open for these types of facilities to take care of us when our doctors fail to do so.
    I think these clinics are a very valuable asset for communities where they are located and are a wonderful compliment to family healthcare when a doctor can not (which is most likely) provide services due to hours, or unavailable appointments.

  • RJS

    …and Stephanie’s comments completely nullify anything the ivory tower types have to say about the matter. You included.
    It doesn’t matter what the AMA says. Even doctors don’t really care what the AMA says because they’re so out of touch with current issues in medicine. No one cares what the motivations behind a company are so long as the end user experience is good. It’s a non-sequitur. A cheap shot that doesn’t have any place in this discussion.
    Until you can compete on the same playing field as the Retail Health Clinics, you’re going to lose.
    “It assumes that medical practices have failed.”
    Well obviously the system has failed, otherwise these retail health clinics wouldn’t exist in the first place. The niche wouldn’t exist if the current way of doing business — yes, BUSINESS — was good enough.
    It ain’t rocket science.
    The problems is yours — as in the average PCP — not the RHC. Until you can meet the average mother’s needs — same-day appointments in a reasonable amount of time — you lose. And no amount of hot air is going to change that.
    Protect your turf if you want. I would if I were in your shoes. But I’d do it more intelligently than standing on a soapbox. Compete or die. The choice is yours.

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