Care-less Care and Telemedicine

One of my irritations with fast track care, especially Kroger's Little Clinics, is the overuse of antibiotics. Living in Louisville, where allergies are king, a simple cold often turns into two weeks of miserably clogged sinuses from increased swelling in already perennially irritated mucous membranes.  A few days ago a new version of "careless care" appeared on my radar. Teladoc advertises itself as the first and largest telehealth provider in the US. Some insurance companies and employers pay for their members to utilize the service. This particular patient used it three times in six months, each time receiving and antibiotic for a "sinus" infection, despite the fact that each time she'd only had symptoms for four or five days. She finally came to see me because the medication the teledocs gave never seemed to help. Go figure.

We spent some time talking about the difference between viral infections and bacterial ones, and discussing the problem with bacterial resistance due to the overuse of antibiotics. She promised to see me with her next episode and appeared rueful that she'd not come in sooner with the previous episodes.

The fact that telemedicine can lead to the overuse of antibiotics has been studied[1]. I was unable to find any studies evaluating overprescribing in Urgent Care Centers so I can only relate my own experience. The ERs and the NP staffed Walgreen clinics in my area do a much better job than the Kroger "Little Clinics" where antibiotic prescribing seems to be more ubiquitous than high fructose corn syrup. 

As telemedicine and other forms of convenient care increase, the fragmentation of healthcare does the same. Did I get any patient information from the Teladoc physician? No, of course not. Almost never do I get documents from the Walgreens/Kroger/Walmart nurse practitioner. I can't fight the convenience and know that as more and more patients have difficulties conveniently getting in to see their primary care doctors, this will only get worse. It is imperative that these groups communicate with patients' physicians. The question is, do I have an imperative to educate the Board Certified Physician who works for Teladoc? And why do I suspect he/she might not appreciate that? The answer is, I need my healthcare system to allow me to use telemedicine to treat my own patients at their convenience.

1. Ateev Mehrotra, MD; Suzanne Paone, DHA; G. Daniel Martich, MD; Steven M. Albert, PhD; Grant J. Shevchik, MD JAMA Intern Med. 2013;173(1): 72-74.doi:10.1001/2013.jamainternmed.305. http://www.webcitation.org/6F5uFLPIY

How tired am I of hearing "the Little Clinic"?

OK, I get it that patients are too busy with their lives to "make" time to see me during the day. That's why I have Tuesday evening hours. But those hours aren't enough when one is sick on another day of the week and need to get better IMMEDIATELY. So enter the "Little Clinic". Physicians have finally taken it to heart that not everyone with an upper respiratory illness should get an antibiotic (in fact, MOST people with URIs don't need an antibiotic) thus slowing down the development of superbugs. Unfortunately the "practitioners" (and no, I don't mean doctors) who work at the "quickie mart" brand of medical care offered at drug stores, grocery stores and discount department stores, apparently didn't get the message. If I had a quarter for every patient who got an antibiotic at those places, I'd be happily supplementing my income. Meanwhile my patients are mystified that the amoxicillin or z-pack they got for their cold just isn't "doing the trick". By this they mean that they are still sick after three days.

Who is overseeing these people? I resent that my patients are getting inadequate care and I resent the systems that are bringing this poor care about--employers that won't allow patient sick days (which is what "allowed time off" is--a way to avoid paying sick time), employers that insist their employees work when they are ill, insurance companies that encourage the use of "physician extenders" because they can pay less for that kind of care, entities (like drug stores and grocery stores among others) that are offering poor care so that they can take another slice of the health care dollar, and patients who think a z-pack will cure every respiratory illness.

"One of the first duties of the physician is to educate the masses not to take medicine."
William Osler