I have just had an opportunity to read an article by Michael Marks, NP regarding his position on Np-Based retail clinics. I thought that I was the only nurse pracitioner alive who echoes his sentiments. I strongly feel that these clinics minimize the wide and varied scope of practice that nurse practitioners offer. Although I understand the niche that has been created by this clinics and believe that these clinics offer fast and convenient care, it leaves the message that our training is only focused on minor illnesses.

I recently took a job at one of these clinics and couldn't be happier. Sure, there is a limited scope of practice but I am completely fine with that. It's a perfect place to work for someone who has no desire to manage chronic illnesses. I am a family nurse practitioner but most of my experience is in pediatrics and women's health. I have never had the desire to work in a family practice setting or to manage any chronic conditions. I believe these clinics are the future of health care and one day may even offer a variety of other services. There is defintely a need for these clinics in many communities!

I am finding this area more appealing as I continue to struggle through the worsening reimbursement issues facing small private practices. I would love to hear from anyone regarding their experiences working in this arena, including how they selected certain ones over others. There are not any in my location at this time, but I would be willing to work to establish one if I felt it represented a good opportunity. Thanks!

I read Michael Marks article also.  I feel it is important to any profession to research and discuss the varied opinions of the members of that profession.  That is how we grow.  I also feel it is important to listen to the people within the profession as we all have strengths and different levels of experience and practice areas.  Also, we all know how important research based evidence is in nursing and medicene.  These clinics brings in another aspect of what an ARNP can do-it does not limit.  This is one of the first things in the history of the ARNP profession that the public is solely exposed to an ARNP.  Let us use evidence based practice and research, grow these clinics, and expand our practice. Give these clinics a chance to grow. Who knows what these clinics will bring and what treatments will be provided in the future (i.e. diabetic teaching, smoking cessatation, hypertension and heart disease teaching and mgmt, the list is endless...)

From the consumers point of view:  Have you ever had a minor illness, called your PCP and they can't see you?  Or how about it is the weekend and your miserable with no where to turn to except an urgernt care center or ER?  Has your child been sick after work and the PCP is closed?  These are the scenerios we see in the retail clinic setting.  These people are so  thankful we are there. And I tell them:  Hi my name is Kim Barnett and I am a nurse practitioner.  This is a not only a "niche" but a huge statement to the profession!!!  Yes , I work at a clinic and am bias.  But when I started reading about these clinics, I wanted in.  I feel the possibilities are endless and I can make my profession shine.

Hi:

I also had the opportunity to read Michael's article and I am glad that someone is speaking to the damage that these clinics may be doing to NPs as healthcare professionals.  I accepted a position with one of these clinics and attended the orientation.  That is as far as I was willing to go.  Not only do this practitioners have a very limited scope of practice, but they are also expected to treat pts under very limited guidelines. I did not get the message that the practitioners were allowed to use their clinical judgement most of the time.  The impression I got from the orientationis that NPs are good for the company's bottom line.  Since NPs are willing and able to multitask and don't have big egoes; in these clinics NPs function as receptionist, medical assistant, cashier and housekeeping (yes, housekeeping).  I wonder what this says about the company's respect of NPs as professionals.

 

The author erroneously concludes that the reason why patients show up in the ER is because of "less than optimum care from primary care providers" - who by the way include NPs. A major reason why patients don't seek comprehensive primary care and slack off on follow up is cost. Some insuraces don't even cover well visits. Given the state of our healthcare industry, retail clinics- who's affordable price is listed offers a welcomed option.

NP in the retail setting are not being cornered to do "little stuff". Time is of the essence for these settings to work and be beneficial to all parties involved, and yes complicated illnesses must be reffered to primary care providers, or an ER visit for those with no primary care providers.

However I agree that NPs must define themselves wherether they provide broad or specialized care. I often refer patients to practices and specialist who have NPs on staff, this way patients learn first hand that NPs are qualified and competent to handle routine as well as complicated illnesses.

I understand where and why Mr Michael Marks, NP feels about retail clinics, however, NPs were created to take care of the "little stuff."  If we want the title and full responsibility of a physician, we should go to medical school.  I think the real issue with NPs is that there is no unified education program across the country.  I am amazed at how poorly trained some NPs are.  Also, the ANA cannot get all nurses to get their Bachelor's degrees, yet we feel the need to push forward and get doctorates.  WHy don't we try incorporating gross anatomy and histology into our curriculum?  If NPs want to gain the respect we deserve from physicians, we should know where we stand and what limits we have to practice.  We are there for patient education and holistic care.  The more you want to be a "doctor," the more you step away from that and only treat diseases. 

 Retail health clinics may seem a little sketchy at first, however, they had the NP in mind.  Typically, they allow excellent flexibility with personal life schedules and a limited scope of practice that allows for minimal, if any, liability.  We are competent, and with education, the "retail" NPs can open up the doors wide to the public to become more aware of NPs and what we can do.  I doubt people will expect NPs to order X-rays and follow up with them at a retail store, yet they trust us enough to seek our care when they can't get an appointment with their primary care provider at that time. 

If it is the case, that retail clinics minimize the wide and varied scope of practice that nurse practitioners offer, then the same can be said for NPs who work in specialties. Cardiology, endocrinology or hep C clinics. Just because we are able to do something doesn't mean that we always have to provide full service care. Retail clinics are meeting a huge need, one part being people who haven't been to health care provider in years who come in for a quick visit, and are referred to a provider that provides care for chronic conditions, based on the discovery of high blood pressure or another issue that needs to be followed in a "medical home". It is because of the retail clinic that we can meet people who for some reason don't seek medical care use our wide and varied knowledge and appropriately encourage them to seek preventative care in a non-threatening environment. 

I appreciate that as NPs we are to discuss our own beliefs and opinions.  We can appreciate that our beliefs and opinions may all be different.  After reading Michael Marks' article Visibility at a Price, I thought to myself, "I have to reply to that article.  He has not ever worked at a retail clinic and is basing his article on something that he has not experienced."  I, on the other hand, work at a retail clinic.  Some might say that my opinion will be biased, but I think that it is only fair to present the other side of the coin.

 Mr. Marks based his article on his perception.  If he were to have spent a day outside of a retail clinic and interviewe the patients having just been treated by an NP in the clinic, I know that he would have a difference perspective from which to base his opinion.  Many patients come to the clinic to be treated for something "episodic" just as they would go to an ER or Urgent Care.  This is episodic treatment.   

Yes, NPs are limited in their scope of practice in retail clinics but so are NPs who work in a primary care office or an urgent care clinic.  We are all limited based on the setting in which we work but that does not EVER, EVER take away from our assessment and clinical reasoning skills.  An NP working at an urgent care clinic may not treat and manage an acute MI but the key lies in recognizing it. 

These clinics are not meant to be primary care clinics.  That is not the purpose of these clinics.  So, is an NP who works in an ER "pushing himself into a corner" because he too, diagnoses routine medical conditions? Yes, NPs are trained to manage chronic conditions and disease processes, but there are also NPs who work in ERs, urgent care centers, etc.  These same NPs who are managing acute otitis media in the ER are the same NPs who are managing the acute otitis media in the retail clinic.  He states, "We must not allow ourselves to be pushed into a corner by continuing to defend our competence to diagnose and treat routine medical conditions that most of us could do in our sleep."  Wow - what a horrible statement that he has made - while treating the "routine" medical conditions may not seem life threatening at the time, please examine the following scenario.  A person comes to the retail clinic for the treatment of a routine otitis externa.  Had she not been seen in the retail clinic, she would have had to wait for her MD to see her or go to an urgent care center and wait hours.  What is the best alternative?  I think that the answer is clear! 

 I do not feel that I have to defend my competence as an NP just because I work in a retail clinic.  In his article, Mr. Marks states that, "In the past several months, I have made many unusual or critical or life-saving diagnoses, and I am not unique among NPs."  That statement that he made includes NPs who work in retail clinics.  Last week I referred someone to the ER because I recognized that she had an infection that required IV antibiotics.

 So, I would urge Mr. Marks to rethink his perception and opinion regarding retail clinics.  We are competent, board certified NPs.  He is the only one who seems to be "pushing us into a corner." 

I am always concerned by the Nurse Practitioner who believes that Nurse Practitioners were created to take care of the little stuff. I would love to invite those who believe this to our practice which serves patients in rural areas and where the office is staffed either by an MD, PA or NP. In this setting and many others like it their is nothing "little" that walks through the door and the scope of practice is limited only by what the MD you work for is limited to do (nothing). That is full responsibility! Any NP in the field can opt to go to medical school if they are seeking the title, but many feel well prepared and have adequate training to be more than competent.

 If you work for an MD which most of us do, you WILL see patients every 10-15 minutes just like any other medical provider and if you can not keep the pace you will be looking for another job. Productivity is a large part of practicing medicine and although it sounds beautiful to say you are a holistic provider who educates, the reality is that as a Nurse Practitioner you follow the medical model of care, unless you are fortunate enough to own your own practice and establish your own rules.

 I would be interested to know the population that the writer serves where she provides holistic care and still makes a profit for herself or the practice she works for.

Essentially we should all support each other. I regret to some extent my first post that stated Retail Clinics minimize the scope of practice for Nurse Practitioners. My concern was not with the work itself or the competence of my peers but the perception from the public and the perception of the writer who states we were created to do "the litle stuff".

Bravo to Michael Marks and to Connie Zak et al who know that these retail health chains are an abomination to the NP movement and NP's as professional providers.  These retail clinics need to be outlawed and real medical practice be the standard of care.  Retail clinics are an insult to those of us who have advanced degrees and  mandate the NP to follow a book to treat patients(like we are brainless without any experience or education), this is cookbook medicine under the guise of evidence based practice.  The horrible thing is they turn people away unless they have something simple like a sore throat, possibly compromising their health to a serious degree; no follow-up, no therapeutic realtionships.  Their motto should be "treat em & street em".  I commend the brave NP's who have made their thoughts known.  I support the AMA in obliterating these "retail models of health care".  Some CEOs are becoming rich on this form of health care(use this term, health care guardedly with retail clinics), because it is not health care.  Frankly have no idea what it is other than a money making proposition to make CEO's quite rich.  As Michael Marks has said, the retail clinics promote visibility of a Nurse Practitioner, but in a negative way.

I feel that I must respond to Ms. Langley's negative comments above. I have worked in one of these "abominations" for the past five months now and have been quite happy with my decision to try the retail health market. It is new to our area and has been warmly welcomed in the community. We provide much-needed services to many people. Some, who have no insurance, or others who have no primary care provider are quite glad that we are here to serve them. We encourage everyone to have a medical home and are happy to assist people with referrals and such. As far as "no follow-up", you are quite wrong about that. Every patient we see for a sick visit gets a follow up phone call in 24-48 hours. I feel that I do work in a "real medical practice" and feel really good about what I do and being able to help patients, who may not have been able to seek care anywhere else. Just because we don't treat chronic conditions or disease management doesn't mean we "are brainless without any experience or education". I've been an NP for 10 years now and have worked many different settings. I have a lot of experience and education and I am quite happy working in retail health. It is the future of health care and I feel that it should be embraced instead of "obliterated". And lastly, I most certainly do provide quality health care to each and every patient I see!!!

I'm going to give Michael and Connie the benfit of the doubt here in that their opnions are given in response to a lack of, or inaccurate information.  I am a 12 year NP and veteran of ER medicine, rural clinics for the underserved, long term care and family practce settings - - I am fiercly protective of the NP profession and of nursing in general.  NP practice some in all shapes and sizes - -there is not a "one size fits all."  I've done the intensive blood and guts, I've done the high level of chronic disease management, cradle to grave and all areas in between.  Retail clinics do have limited scope of services , intentionally(not practice) - -the sore throat the cough, the rash, while not life threatening, require treatment non-the less.   We do not have a cook book and this is not encouraged with my company - - critical thinking is encouraged and celebrated.  The company that I work for is "NP Centric" -- the only position I have ever had that not only talks the talk, but walks the walk. 

 It may not seem "sexy" but the service provided is necessary - - it is providing access and affordability, 2 things sorely lacking in our current health care system. As for quality, I can only speak for my company - - the services provided are gold standard with peer to peer review, doc review with a robust collaboration. In November, the AMA made a public statement supporting this much needed service --- initially, they had the same opinion that Michael & Connie have expressed -- however upon engaging with the providers and investigating further, they ammended their position.  Finally, my hope for Michael and Connie would be that they think a bit before using words like "abomination" as descriptors when referring to the venues in which their sisters/brothers practice.  I will agree that not all retail clinics are created equal in culture or quality (same holds true for clinicians, hospitals, docs, venues, etc.)  the quality one's will rise to the top, the sub standard ones will go away.

Thank you. 

 

After reading the above listed editorial by Debra Rangley, I am in shock.  It's as if I read Michael Marks' article all over again.  I can appreciate the differences of opinions but these editorials are so negatively biased, I really cannot comprehend this.  She says that retail clinics "treat em and street em."  I work for a retail clinic, and I have called EVERY SINGLE patient I have ever treated to follow-up.  Who says that there are no therapuetic relationships or follow-up?  This kind of statement making without fact is absurd! 

Also, I would like to point out that I do not practice cookbook medicine.  I work for a place called "The Little Clinic", and I make my own decisions.  I do not follow as script or cookbook as she is referring to.  I make decisions based on evidence based guidelines.  I tailor the therapy and recommendations to the PATIENT!  I use my brain and what I was taught in school!

Debra also makes the statement that we turn people away if it's not something simple.  Quite untrue Ms. Rangley - please consider that if you're a primary care NP, you are not going to treat an MI.  Yes, you might give 325 mg of ASA, perform an EKG, and subsequently call 911.  How is turning away someone compromising their health if you make the necessary referrals?  I have not "turned someone" away without making the necessary referrals and recommendations.  I had a patient last week with an irregular heart beat and palpitations.  She was quite unaware of her irregular heart beat.  I immediately called report to the nearest ER, made arrangements for her to get to that ER, and called this patient the very next day.

I am quite concerned that people think that puppets are working in these retail clinics.  I am not a puppet - I am a competent, board certified, family nurse practitioner who enjoys working in a retail clinic because I help people.  I make the appropriate referrals, I perform health counseling, and I do not practice from a cookbook.

So, Ms. Rangley, when you feel like you want the AMA to obliterate these "retail models of health care", please remember that where you work, the patients pay, and you get paid.  Isn't that retail of some sort? 

She also proposes that CEOs are becoming rich off of these models.  The Little Clinic which is based in Nashville, Tennessee, is funded through an organization who owns the Greenwise products in Publix and Latina Magazine.  It is not owned by some CEO who is "getting rich."  It is an organization that sees a vision for healthcare - episodic care for people who desperately need it.

So, the next time you are suffering from a UTI and can't get in to see your doctor because it's the weekend, before going to your nearest ER or Urgent Care, I invite you to come by and see me.  I not only will help provide relief, I will educate you on the medication, your health, and the health recommendations for your age. 

I am such a proponent of retail clinics because we are providing a service to uninsured and insured members of our community.  So, the next time you feel like lobbying to the AMA to "obliterate" my clinic, please reread what I have just wrote.

I am a PA who was a Manager of Operations for a Retail Health chain in NY. I hired thity NP's to start this operation. My honest comments are that this is not a job for everyone.

Yes, the clinican must adapt to a slower pace, less challenging patient presentations, etc BUT the positives relate to the service that is performed for the patient and that the EMR is always sent to their private medical office or a local medical practice is given to the patient.

I consider this to be the very best opportunity for APC's who are older and have proven themselves and now choose this as a semi-retirement job. I hired two new NPs whom i suggested that after getting their feet wet should sek out other emplyment in an area of intest to prevent them from becoming satisfied in just working for the retail clinic. All in all, it is a new paqradigm that is now proven....and I support it .

I am now back in surgery with the doc with whom I have worked for over thirty years but I will return to a retail clinic in semi-retirement as a clinician or a manager.

Bob Blumm