Tightly Scripted: One NP’s Experience with Retail Clinics

By Karen Roush, MS, RN, FNP-C, AJN clinical managing editor

Retail health clinics (walk-in clinics that are in a retail setting such as a drugstore or discount department store) have become an effective mode of providing increased access to care for many people and a growing source of employment for nurse practitioners (NPs). Their place in the health care arena may take on even more significance as the Affordable Care Act (ACA) increases access to care for previously uninsured people.

I worked as an NP in a retail clinic for about six months while working on my PhD. I left because of concerns I had about the model of practice. It didn’t have to do with the fact that I had to mop the floor at closing time or collect the fees and cash out the “drawer” every night. Nor because I spent eight hours alone in a small windowless room tucked away in the back of a drugstore. Those aspects were not great, but they weren’t deal breakers.

What was a deal breaker was the rigid programming of my practice. The computer was in control. From the moment the patient checked in at the kiosk outside my door, every action was determined by the computer.

The organization I worked for prided itself on following evidence-based practice, but someone forgot to tell them that the patient’s history, presentation, and personal experience, as well as a clinician’s expert knowledge, are also part of the evidence. And as much as they insisted the programming was guided by evidence, it was clearly also guided by what would result in the highest level billing code.

From the moment I entered the chief complaint in the computer, it directed me on what to include in the history and what to do for the exam. The problem was that unless I filled out all the information, I couldn’t go on to the next screen. Say I have a feverish four-year-old with tonsillitis, screaming in her mother’s arms, and the computer insists I take her blood pressure. Why? Because there is strong evidence that strep throat is associated with pediatric cardiovascular disease? Nope. It’s because the more systems you include in your exam, the higher the billing code. As a result, I find myself struggling to take an unnecessary blood pressure, causing unnecessary distress for a sick toddler. But unless I put a value in the box asking for the blood pressure, I can’t proceed with the exam.

Or a healthy 20-something adult comes in with poison ivy. Half an hour later he leaves with a script for cortisone cream and I’m feeling foolish having listened to his heart and lungs; taken his blood pressure, pulse, and respiration; checked his extremities for edema, his pupils for symmetry and reaction to light; asked him about headaches, appetite, abdominal pain, cough, fatigue . . . hitting on the respiratory, cardiovascular, neurological, gastrointestinal, and yes, integumentary systems. And presto—what should have taken 10 minutes and been a low-level office visit jumps up to the next or higher level and wastes both our time.

But the billing aspect is just one part of the problem with the computer controlling the visit. The worst part is that it interferes with two really important skills—critical thinking and intuition based on experience. I couldn’t get the computer to follow my thinking when the history or exam led me off its chosen path. The essence of an office visit is found in the interactions between the patient and the nurse. It cannot be scripted—you have to be able to go where the history and exam take you. It is an iterative process that requires critical thinking and intuition and it often doesn’t follow a neat little algorithm programmed into a computer.

I talked to the regional director about my concerns and she told me that they had recognized it as a problem and had made changes. But I didn’t see any changes that allowed me to practice to the best of my knowledge and ability.

The other reason I felt I had to leave was the expectation that I would not only be a health care provider but a salesperson as well. When I applied for the job the regional supervisor told me that some NPs had trouble with the “retail concept”. I assured her it wouldn’t be a problem. But I didn’t realize what that meant. I didn’t realize it meant I was expected to drape my stethoscope around my neck and walk around the store to drum up business (an instruction I ignored). Or that I was to promote certain products—screenings and services. That I would be evaluated based not only on my patient care, but on how many summer camp physicals I did compared to NPs in other stores. Or that I was always to proceed far enough with a visit to allow billing, even when I knew that I could not treat the patient there and would have to refer them on to an area emergency room or urgent care center.

Retail clinics serve a need in health care and I don’t think they should go away. The fees are reasonable compared to other settings and they are open when most primary care offices are closed. There were many patients I saw who were uninsured or underinsured and would not have gotten care if the clinic wasn’t there.

But some changes are needed. First, there needs to be a wall between sales and patient care. We are nurses, not sales clerks. Second, they need to have a model of practice that takes optimal advantage of an NP’s skills and knowledge. As they are now, or at least the one I worked for, they are not designed to allow an NP to practice to the best of her or his ability—you may be on your own in the clinic, but make no mistake, you are not practicing autonomously. All of your decisions have been programmed into the computer. That is not good practice, and it affects the quality of care the patients receive.