How do you prescribe ABX in a retail clinic?

[criticalHP, MSN, RN]

I am a FNP student 8 weeks into my first practicum rotation. I'm mostly in a busy clinic office, but twice I was asked to go to a retail clinic. The clinic is staffed by one NP and a receptionist in a moderately busy outlet. The NP is limited to what can be seen and treated, so basically only ENT, GU. No lacerations, suturing, GI, chest, wheezing...you get the idea; Its quite basic. I'm glad for the experience, don't get me wrong..I can spot a sinus infection across the room now:yeah:. There were some things that bothered me about the politics and the prescribing of antibiotics in the retail clinics, and I'd like to get some opinions from working NPs from all clinic areas before I make up my mind on what is right.

Firstly retail clinics are a retail business, and without customers that business, like others, will not succeed. People pay $xx to be treated for whatever illness they have. If they are happy with the service, and perceive it to be of value they will return.

What I have a hard time with is that people except an antibiotic along with their $xx fee, even when it is clearly not indicated. I saw people with no fever, clear sinus drainage, no HA, no cough were diagnosed with a sinus infection (and URI) to justify an ABX. The NP I was assigned to said that is what they expect, and if they don't get it they will go to our competitor up the road. If they go to the competitor we loose revenue, and I loose a job" There was no need for me to mention antibiotic resistance; I could read that she felt uneasy and ashamed about this practice all over her face, and I really felt she was in an ethical dilemma within herself.

So then, here is the issue: Do we prescribe antibiotics without justification in order to ensure customer satisfaction, good community reputation, and return on investment for the parent organization? Or do we help prevent the development/spread of ABX resistant organisms, and hope the patient understands we are doing this for the good of the HC community as a whole, plus saving them from possible SE of the ABX? (remember, most of these people are uninsured and pay out of pocket)

I suppose one could refund their money if they do not Rx an ABX. This would satisfy the customer monetarily and increase trust in the clinic, but then the NP is not making the clinic money, and less business income means over time equals closed doors and unemployment lines.

I would love to hear all sides of the issue. I will likely end up working in one of these clinics at some point, but will I compromise my clinical work ethic for the sake of a having a job? I've been an ICU and ED nurse since 1997, and I have always worked to protect my patients, even when it ended me in hot water...I was doing my job as a patient advocate.

One more issue...the dark side ...I notice in my geographical region there are NO physicians that run these retail clinics, in fact they removed clinic services from the local ED's. Given the scenario presented could the retail clinic undermine NP validity in the eyes of physicians, and is this intentional?

I appreciate all feedback.

[Adenium]

This is disturbing to hear, especially given the increased awareness in the medical community as well as in the public regarding abx resistance. I have met folks in the last few years who were given abx by their doctors, too, for a cold....not a bacterial infection. Because the doctor gave it to them, they insisted there must be a reason. The doc didn't discuss it, just gave them the prescription and sent them out.

I wonder, though if these patients would still feel they were getting adequate service if the reasoning were given to them. "These are your symptoms, they suggest X is going on, X is not treatable with abx so I am advising rest and hydration, etc. rather than abx to save you money and unwanted side effects." It doesn't take that much time. If someone told me I was fine and sent me out the door, I'd suspect poor care. But a logical reasoned response? I think I'd feel well taken care of.

The NP that suggested doing it because the patients expect it seems a bit lazy as well as unethical. They might expect narcotics and a backrub, but we don't just hop to it.

[criticalHP, MSN, RN]

Very nice reply. The NP did in fact explain their (rapid strep) was negative. She would then write the script and say if you feel you need it after a couple of days, go ahead and fill it. One reason she did this is that as a retail clinic there is no lab for which to send the strep swab to cook overnight...and they do occasionally come back + on the cultures. So, they have paid their fee, got a negative result. If they walk out of the door with no script and feel lousy in 2 days they can come back (pay again), go to the ED (where they never pay), or go to the competitor--who will likely give the ABX for the same reasons.

Lazy? Perhaps. I can see that at first, but she did educate every one whether they listened or not, and having a NP student in front of her likely encouraged a bit more education on her part than probably occurs.

thanks again for the post.

[Adenium]

Aha. I was overly harsh assuming there wasn't the education going on as well.

[criticalHP, MSN, RN]

No probs, and your first instinct is usually the correct one, that is if the original poster gives you all the info (shame on me- it wasn't intentional) :uhoh21: . I felt she was a bit lazy, too. But it did get me thinking about the business angle.

[Spacklehead, MSN, NP]

I honestly think you had a bad experience at one specific retail clinic. They are not all like that.....and I'll leave it at that.

[CRF250Xpert]

I have seen people Rx ABX for everything that they aren't supposed to be Rx for. You have to ask things like, when is a CXR indicated for bronchitis and what is the first line ABX? Answer - never and none, but what do you see folks go home with for bronchitis?

I have never worked "retail", but was considering some moonlighting. I know for a fact it's not setting specific. I see all sorts of wrongful ABX use and it's not simply NPs doing it.

I did want caution on predtermining stuff like "spotting a sinus infection". These are so frequently misdiagnosed as they can be many things. Remember recurrent or chronically they can be GERD Sx or a fungal ball. Just food for thought. Have fun.

[mammac5]

The thing is, whether in a retail setting or a private clinic setting, we all have to make money to stay in business. A NP who cannot pull his/her weight financially is not going to be employed long, no matter what the setting.

Having said that, we need to also realize that if we practice medicine like a vending machine (patient puts in the required amount of money and a prescription pops out for them) we are cheapening the profession for ourselves and others. We devalue our services when we practice in a way that bows to consumer pressure rather that using a scientific, evidence-based approach.

[sandnnw, BSN, MSN, EMT-B, APRN]

Good answers everyone. I'll chime in here with your "gut" also plays a role.

I NEVER give anyone an Abx within the first week, unless they have some type of objective finding, and even then there are over lapping findings between bacterial, viral and allergic symptoms. There are also hx issues, including smoking, COPD, lowered immune systems, tonsils and recurrent infections per age groups. I don't see children, but I can imagine the peds population might be the most difficult to deal with (parents). In saying this, I do see a few 12+ kids and have run across mothers and dads who are insistent on Abx. I do give them the option to call back or write an Rx, looking straight at the child and telling them, don't take these unless you don't improve after FIVE days, getting the huffy mother out of my clinic asap. The rapid strep also helps us, although I don't have it available in my full time job.

I believe with time and confidence, most folks develop a knack for explaining the watchful waiting approach. Rarely do I get on the defensive or sternly explain when they really do need an Abx, it might not work, increasing resistance. We discuss this at work, and one of my MDs just gives either Keflex or Zithro, noting the high resistance, and magically, 99% get better within a week. I won't even get into the "magic" steroid shot routine. What a money maker!

I can imagine the pressure at a retail clinic. I have never worked at one, but the co-dependent relationship would make a great analysis paper. Retail folks, continue to share. This is one of the more interesting topics of late

[pedspnp]

I am known as the antibiotic nazi , I refuse to order abx unless exam indicates other wise. I have had angry parents leave and call the office to leave a message for the MD to call them, he calls and of course he orders antibiotics with out seeing the patient or even bothering to look at the chart his

[sandnnw, BSN, MSN, EMT-B, APRN]

Amen! And, it makes him look like a hero, you like a turd! But, at least we can sleep better at night, knowing we followed researched based outcomes

[CRF250Xpert]

I am known as the antibiotic nazi , I refuse to order abx unless exam indicates other wise. I have had angry parents leave and call the office to leave a message for the MD to call them, he calls and of course he orders antibiotics with out seeing the patient or even bothering to look at the chart his

That sounds about right. I bet he gets great annual reviews from the CMO too since his PTs never complain. Amazing.