This week the New York Times reported that Walmart intends to set up primary care clinics in their stores. According to the closing paragraph of the article:
“To make it profitable, you need to make it have more than just a clinical encounter,” said Dr. Glenn Hammack, the founding president and chief executive of NuPhysicia, which closed the six clinics it briefly ran in Walmart stores. “You also need to sell them prescriptions, a bag of chips, maybe a magazine while they’re waiting.”
The news was met with concern on this side of the world. Australians are all too aware that what starts in the US is a sign of things to come. There was talk of:
Dumbing down of general practice
Others thought that:
This change is coming. Patients want it. Government want it. Patients vote.
While the debate continues I was reminded of Joanne (not real name, nor actual details) who presented with her three little boys a few years ago. She looked exhausted and said she needed something to help her sleep. Before long I had to rescue one of the boys who had lodged himself under my desk. Meanwhile his brother, with Down’s syndrome, was climbing onto my desk to get at my key board and the youngest had crawled into the bin. Joanne was weary. I noted that she had been seen three times already in the last month and had been started on an antidepressant. There followed a long discussion about her migraine headaches. Her love of chocolate, her recent pregnancy, her need for better contraception given that she could no longer take the oral contraceptive. Then a discussion about life as a single mum. In time she become a bit more comfortable that I hadn’t yet reached for my prescription pad or interrupted her. She said something that didn’t fit the story of a single, stressed struggling mother- she told me:
And I get breathless on the slightest exertion and have lost quite a bit of weight.
Something wasn’t right. This did not fit the story. Anyone could see how she might be worn out by her situation, but this was something else. Her resting pulse was 120. She had lost several kilograms in the past few months and was not dieting. Despite the cold she was wearing a loosely fitting dress and sweating. A couple of urgent blood tests later we established the diagnosis. She saw an endocrinologist and when we met again she was feeling a bit better- except that she continued as the mother of three demanding young boys.
Joanne, and the many other Joannes, that attend general practitioners every day have no idea what’s wrong- only that there is something wrong. They want the time and space to tell their story to someone they trust. This isn’t going to happen at a supermarket fast-diagnosis clinic where the goal is to issue a prescription and making a sale. There is no such thing as a ‘quick consultation’ in the context of ‘minor illness’. Joanne would have left the surgery with a script for a hypnotic- she needs to sleep but what she needed more than that is to be seen and heard. The crunch often comes- as it did in this case when the patient is about to leave the room- the ‘while I’m here doctor’ moment. Perhaps someone with asthma might know they need an inhaler- but can we assume that someone with relatively minor symptoms would recognise that their tolerance to those symptoms was reduced by some other physical or psychological problem (pneumonia, exam stress, divorce, bullying) that warrants more than a quick trip to the pharmacy? It is assumed by some policy makers that doctors respond to disordered machines (mechanics), rather than to distress. It has long been established that:
The overall prevalence of symptoms in the community is not closely related to general practice consultation rates, and the consulting population is a selected population of those who are in need of medical care. The literature review suggests that poor health status, social disadvantage, poor social support and inadequate coping strategies are associated with higher consultation rates. Some population sub groups may experience particular barriers to seeking care Campbell and Roland.
Does Australia have anything to fear from commercial organisations seeking to cash in on minor illness? Is it likely that it will reduce the demand for traditional GP appointments? I suspect not, if only because of Joanne. What we have learned about why people make appointments to see doctors is that they are far more discerning than we give them credit for. What for-profits will achieve is to rekindle the debate about whether people would be sufficiently enamored with a watered down version of a consultation with a general practitioner to walk away from the queue. Experiments in offering people alternatives to general practice in the UK were not successful. Renewed attempts to test the ‘market’ again will only delay a commitment to the only service that keeps the cost of health care under some sort of control- general practice.
Picture by Anne.