The Wisdom of Thornton Wilder

When I was in 7th grade, I think it was, my whole family — Mom and Dad, Bobby, Kathy, and Emily — trooped out to the Friends’ Central School Senior Play to see me say my one line as Wally Webb in Thornton Wilder’s Our Town. “Aw, Mom, by 10 o’clock I have to know all about Canada,” quoth me as Wally. Then I trooped off the stage to school with a senior playing George Gibbs as he tried to ingratiate himself to me as a route to my sister Emily Webb’s heart. It was a spare production, as Our Town productions generally are, since the part of God is taken by the Stage Director who speaks directly to the audience, so it’s a play within a play, and since the Stage Director has to move sets easily with the audience watching, they are minimalist.

I was only 13 or 14, I guess, but I got that part about God, even if not using that word. When my sister Emily Webb asks the Stage Director if she can go back in time and see her family and herself as it was years ago, before she died, he can do that for her, even though he advises against it. He could have said “You Can’t Go Home Again,” but that Thomas Wolfe book was actually published two years after the 1938 first production of Our Town, so he didn’t. But going home again must have been in the air then, or maybe it always is.

Wilder’s Grover’s Corner was pretty far away from Philadelphia’s Main Line where our performance took place, but it didn’t seem that far away to me. Traveling to the Main Line was already a stretch from West Philadelphia, where we lived not far from the Penn campus on 47th street, around the corner from our friends the Levin’s, the Egnal’s and the Kagan’s, all Jews like us, first and second generation after the great Eastern Europe Jewish migration of the 1890’s, all professional families, and all determined that their children would have full educations and full opportunities in life. That was what our ancestors had gifted us with, and the sense of mission hung heavy in the air even though usually just implicit.

We were assimilated, as my mother explained to us. We loved Philadelphia, we loved baseball and basketball and football, the A’s and the Phillies and the Warriors and the Eagles; but we also knew we weren’t from here originally; we knew our history as filtered, in our case, directly from our parents, since my mother didn’t like her parents very much, and my father didn’t like his mother very much and his father had died when my Dad was 17. We heard about ancestors from time to time, and my mother had two wonderful childless aunts whom we were close to, and years later we would see the pictures of the larger family that came over, with beards and European clothes, with some Jewish first names, but nothing religious, since my family didn’t believe in religion. We knew my father’s maternal family were bankers wiped out in the depression, and my father’s father was a doctor and Philadelphia champion pool player, harried no doubt my his wife, who was that sort of person. My mother’s family was in retail, and my aunts looked back at the 20’s with wistfulness, the way we look back at the 60’s and 70’s. So we had a sense of where we were from.

Ambitious but frugal, insecure but confident in abilities, and willing to defer gratification – in short, we fulfilled the Tiger Mom formula for “success.” We got to Friends’ Central when my Henry C. Lea Elementary School 4th grade teacher, Miss Ousey (“Lousy Ousey”), committed the cardinal sin of having a low bar by telling my parents enthusiastically that I “was definitely college material.” “'College material', really?” As ambition trumped frugality (and a Commie past), they found that the liberal Quakers of Friends’ Central welcomed Jews, so off we went just over City Line Avenue, into suburbia-land, just barely outside of Wilt Chamberlain-Overbrook High School land. (Nowadays Friends’ Central isn’t the only welcoming school — Episcopal Academy advertises in the Jewish Exponent. Progress!)

When I got to 7th grade the Friends' Central curriculum included a course in public speaking – one of the good ideas that has probably been dropped as education spirals downward. The teacher, Mr. Richard “Dick” Burgess, was a tall, thin man with close-cropped hair and a bow tie, who held himself quite erect, and who had a way of speaking that had him constantly overcoming a tendency to swallow his words – thus qualifying him to be the public speaking and drama teacher. He smiled easily even as he seemed to fight a tendency to swallow his smile. His sunny disposition always won, and he exuded enthusiasm and warmth even through his introversion. In short, he was endearing, the best sort of private school teacher.

His public speaking course presented scenarios where someone would commonly be called upon to speak publicly. My opportunity came as MC for a class variety show. When I displayed flair, enthusiasm, and wit, Mr. Burgess had a find! Full of suppressed enthusiasm, he dropped down on a knee – he was indeed very tall – and asked me hopefully and expectantly if I would like to be in the senior class play, Our Town, playing Wally Webb. Seeing his enthusiasm I really didn’t have to think at all, I just said yes. He told me about the weekend rehearsals, and I said yes. Who could say anything else to Mr. Burgess? Maybe I was a little scared, but I knew my family would back me, and I always said yes to dares.

My mother was thrilled and loved Mr. Burgess, and for weeks she drove me out for day-long Saturday rehearsals. I hung around with the stagehands, ate my bag lunch, generally gaped at everything, and was kind of adopted by the cast. I still remember how I could hardly believe how they adopted me and instructed me, especially since my own 7^th grade class had a distinct anti-Semitic tinge. One burly guy was a stagehand, and showed me how to carry heavy items by standing tall and straight. As an eldest son, being adopted and nurtured by someone older but of my generation was very new.

When the time came for actual performance, my whole family trooped out with enthusiasm and expectation for opening night and my one line. I remember my mother telling a friend, thrilled but embarrassed by her enthusiasm, “We all went out for Buddy’s one line!”

But my one line was only something to be nervous about and get over with. What I remember more was when I was quiet. The Stage Manager, a senior named Bruce Beckwith, held his clipboard as he addressed the audience directly, and I sat on the stage on a folding chair with others in the “cemetery” next to my sister Emily Webb. My appendix had ruptured on a Boy Scout hike, I think.

I remember Emily, who had recently died, asking the Stage Manager, can’t you ever go back? The Stage Manager says, yes you can, you can go back, but I don’t recommend it. Emily says, but I want to go back! I want to see Mama! Don’t do it, says Bruce the Stage Manager, I recommend that you don’t do it. But if you want to, you can. Emily says, yes, I want to do it.

So she does. The Stage Manager takes her back to a typical day in the past, the least significant day possible, with Mama getting breakfast ready for the family, saying the typical things that she said, get ready, come on now Emily, it’s time for school. And the dead Emily calls out, Oh, Mother, you’re so young! Look mother, here I am, can you see me, let me tell you what happened!

But Mama can’t hear her, and Emily is overcome by emotion, and cries, and after a while goes back to being dead, and tells the Stage Manager he was right, it’s best not to go back. I sat there on stage and watched. I saw how they felt, but it was hard to understand. I was in seventh grade, after all. But I remembered.

Now I’m far older than Mama was when Emily went back. Not only am I older, the world is older, too. When the Berkeley-born Wilder wrote that wonderful play in 1938, technology was just getting started. Recapturing the past had progressed some, but it was still pretty impersonal. Recapturing had started with the most incidental reminders of all, fossils, then actual manmade paintings on cave walls, then memorized sagas, and mummies, and temples and statues meant to last and show to all, then words in copied books and printed books, then onto photographs, recordings, and movies. So Wilder did have at his disposal many technologies that recaptured the past, and they must have been wondrous to him, because he was obviously so conscious of time, not only in Our Town, but in Back to Methuselah — what could be more about time than that?

My father, too, had a sense of time and events. He used an eight millimeter home movie camera to record our family, and so did my Mom, my grandparents and great-aunts walking down steps and smiling one after the other, my father throwing me up in the air and catching me, my mother walking to the beach in Beach Haven and smoking, Play Day at the Henry C. Lea School where I got lost in the kindergartener’s dance, and even one of me playing basketball on a dirt court at camp, missing an easy shot off the left backboard, not quite high enough.

Eight mm was pretty personal, but now, some 60 years on from the Friends’ Central Our Town performance, we have the most personal of all the time-cheating reminders of all, we have videos, with full voice, with a long enough time frame that people don’t have to hurry, you can just be yourself for a few hours and be totally recorded. Videos of everyday life as it really is.

Photography was my hobby as a kid, and imitating my father, I guess, I filmed videos early. When I visited Philadelphia I would even rent a video camera, leaving the clunky early models I had at home. In 1986, 1987, and 1988 I took my parents, who were then about 70 and very vigorous, and we drove around Philadelphia together to where they had lived, and where we had lived. As we drove around in the car I interviewed them as they added comments to each other and contradicted each other and did what they usually did, and I also sat them down in their home in Society Hill in central city Philadelphia and interviewed them about their lives. My father had an allegiance to truth and significance, and he started talking about how he had a case, a family member of a friend, who needed a spinal disk operation which my father performed, but his resident had bad acne and probably contaminated the field, and the patient got infected, and my mother said “Don’t talk about it, Henry!” but he did, and he said, “It took him so long to die.” Being a neurosurgeon is still very hard, but it was harder then, I think. I have it on tape.

So, I have lots of tapes of our lives. The day we told the four older kids that Ann was pregnant with an embryo who would become Peter. The kids washing the dishes as their chore, that extended for a very, very long time at the sink. Lots of things. The old eight mm movies of my parents transferred to DVD format. And the interviews with my parents.

So I sent all the DVD’s out to all the kids, and I sent the videos of my parents' interviews out to Bobby, Kathy and Emily. I haven’t heard much from them. Bobby said it was hard to watch, that he started to cry and so he stopped, I think he said. Kathy said, God, what was the big deal with Mom and Dad talking about how to get to where they wanted to go in the car, what was that all about? But she hadn't gotten around to watching them much. Emily said she already had a copy of the 1987 interview and kind of brushed it off. Actually, I don't think I even got thank you's from the girls. But I take that not as a lack of gratitude, but resistance. This is hard stuff.

Me? I think it’s hard to watch. I watched all three of them, but I had to get ready and set the time aside, and be at at my desk doing something else while they were playing on the TV at my left side, so I could tune out or tune in, although in truth I tended not to do much else while I was watching, I just had other stuff available. I get so sad for the world that no longer is. Love, sadness, and feeling the depredations of Time’s Arrow. Nothing stops time, We exist in the memories of others and then not even that. We love and lose, no evading that. You really, really can’t go home again. If you’re strong, you can go back now, and I did. But it’s also defensible to listen to the Stage Manager.

Budd Shenkin

More Advice For Hillary

Where would Hillary be without my advice? Talk about priceless, that's what my advice is, totally without cost to her, and probably to me even if I err, despite the fact that I have tens of readers (actually, my best post has over 1,000 page views, but mostly they vary and a good one gets 100+ page views. My Hillary page views, perhaps not so much.)

So, today, three points.

The Server and the Emails

She's in a pickle. Comey really skewered her, and she deserves it. She shouldn't have done it, and then she shouldn't have attempted the equivalent of a coverup, saying it was “convenient,” etc. It's obvious she wanted to hide stuff – and given the way she has been attacked in the past, that is certainly understandable. But, still, she did something she shouldn't have done, Clinton-style, and then lied, Clinton-style.

I think I'm an outlier, but I look for chances to admit I was wrong and to be humble. I think, so should she, and this is the perfect opportunity. If she does that, she gives people the chance to be empathetic, and to view her as human. If she is always defensive and I was right and I have a plan and I will be your champion, well, who can be empathetic? So, my advice is, take the heat and do a real mea culpa – although, truthfully, could she do this? But, if she could – she is enormously self-disciplined, except when she isn't (I suspect her lack of discipline comes from her melding with Bill, the Southerner, who allows himself a lot, the way Southern scamps do) – she should say,

“It was a stupid thing to do. Even smart people do stupid things, and that applies to me. I wish it weren't so. Human beings make mistakes, and that includes me. Being human is an exercise in being humbled. I'm so sorry I did this stupid thing.

“I wish I could say I'll never do anything stupid again, but we all know that's not true. I did learn from this, however. I won't do something stupid like this again. The next stupid thing I do will be completely different. (OK, she shouldn't say that, but I couldn't resist.)

“But, when you do a stupid thing, you really should learn from it. Here is one thing I learned from this episode. I did this on my own, and I didn't have anyone to say, 'Don't do that, it's stupid.' If I am elected President, I pledge this: I will not be a Lone Ranger. I will work with a team, and make sure that the people I work with are smart and well-informed, and also that they are not afraid to speak up and challenge me. It will be up to me to make sure I have strong, independent voices around me, and I will do that. I'm going to involve a lot of people I appoint, and I'm going to involve people in the Congress – even Republicans. I'm going to make sure that when we take steps, that as many people as possible are on board with it. Because nobody has a monopoly on intelligence and judgement.”

I figure that's the best she can do. Mea culpa, eat humble pie, make a pledge. Be human and not defensive. Let the Republicans rail against her, and sympathy will be on her side. Give herself a chance to be human. Then let it die down prior to the convention.

Vice President

So, that's the emails. That's defense. Now to offense, to the convention. Hillary needs to create some excitement. Just because she's a woman, that's not enough. She needs some pizzazz, and she needs it from somewhere else. Not Bill, please! He's past his sell-by date. So, do what?

I think she needs to bring on Elizabeth Warren as her VP running mate.

I didn't think it was a good idea before now. I thought it would be unbalanced, somehow, too out there. But now that I've seen them together, I think that's who it needs to be. Balance, schmalance. Her husband Bill didn't go for balance, he went for fellow young Southerner Gore. They were a great electoral team! Young, dynamic, exciting, not paying off this one or that one or getting this state or that state, no John Sparkman to offset Adlai, not at all. I think she needs to double down. EW is great on the stump, and Hillary can be the sage and experienced part of the team, the one who knows well how things work. And EW can not only bedevil Trump, she can excite the young and the jaded for turnout, and I don't think she will overshadow Hillary, because she will know and respect her place. No Sarah Palining for her.

They say that there are July, November, and January VP selections – to get the nomination, to get the election, and to govern. That's what they say. My wife Ann worries that they wouldn't get along for the January part of the deal. She might be right, but I think there's a chance that they would. EW is fiery, but she's very smart and mature, and I don't think she will threaten Hillary. The potential pothole for EW, and for any VP who would want to be included in governing, is Bill. After all, the biggest trouble Gore had with governing was Hillary, who kept edging him out. Would Bill do the same thing?

He would try. He would certainly try, entitled as he feels he is – and he does have some entitlement legitimately, he is a former President. I can see him edging in, or barging in, or fighting his way in, completely ruining things for Hillary. The Big Dog comes back. I can see it. I can see him undermining EW, or any VP who wants to do something in governing. That's the big unknown. That's something EW would have to have assurances about before saying yes. But for sure, I think EW would be a great November VP selection. Pizzazz! And a show of confidence from Hillary, that she will follow through on her promise to be open to strong people in her innermost circles.

A few months ago I speculated on what the December meeting between Hillary and EW was about. http://buddshenkin.blogspot.com/2016/01/between-elizabeth-and-hillary.html. We still don't know what went on there. I doubt very much it was VP talk. But EW sure has played her cards well. Myself, I'd put her right on the ticket and tell the Big Dog to stay a vegan – no eating meat, Big Dog.

Good luck with that.... But it's what Hillary needs to do.

Running with a Message

Hillary is about substance, Trump is about appearance. Hillary needs pizzazz, but she needs a program. She has a lot of programs, but she needs a Program. Put America To Work would be a good one. She actually has taken my advice, I notice! Over a year ago, I suggested that she concentrate on infrastructure. http://buddshenkin.blogspot.com/2015/05/more-advice-for-hillary.html. It's a winning argument. Now columnist Carl Leubsdorf reports that in responding to questions on her priorities, her first was: “In my first 100 days, I will work with both parties to pass a comprehensive plan to create the next generation of good-paying jobs. The heart of my plan (Hillary, would you stop saying 'my plan' please? It's a 'me' statement, not an 'us' statement, and it's bureaucratic. Say “We should thus and so.” Tin ear.) will be the biggest investment in American infrastructure in decades.”

Good! Build on this. Push the details, push the vision, emphasize how well this is thought through. This is your strength. Add all the other good stuff that is coming out, taking stuff from Bernie, etc. That's great. All of it will show off how smart you are, how you can govern, where you want to go. But “infrastructure” has a lot going for it, I'd say. It sounds so workmanlike.

And it can be in speeches, not in emails, thank God.

Budd Shenkin

Retail Based Medical Clinics

There is a debate in the American Academy of Pediatrics about what position to take vis-a-vis Retail Based Clinics (RBCs).  Yes, some argue, there are certainly problems with them, but they are here and not going away, so shouldn't we work with them and try to make them as good as possible?  I don't agree with this.  I think there are structural flaws that will make their quality always unacceptable, most probably, especially when dealing with sick kids.  I also think that dealing with them "because they're here" is not a great argument.  Do the Republicans think they can control Trump if he wins?  What about the gamble of Franz von Papen?

Anyway, the AAP came up with a draft paper that I didn't like.  So I criticized it, and then, so as not to just be negative, I thought the responsible thing was to come up with a substitute that I thought would do a better job.  It's a little long, almost 4,000 words, sorry about that.  But I like it, and maybe you will, too.  If you're a non-medical person, hell, just skip it!

Budd Shenkin


                   Proposed AAP Position Paper: Retail Based Clinics


Retail based clinics (RBCs) have proliferated as a new venue for providing health care to patients in the United States.  Since their founding in 20xx, they have proliferated to the point where most major retail pharmacy companies host them in their stores, and the number of visits is up to xxxx in 20xx.  While most visits are for adults, children are also seen.  The best estimate is that xxxx pediatric visits were made to RBCs in 20xx.  The original intention was for RBCs to see patients for acute problems only.  Recently, however, there has been mission creep, and RBCs are advertising other services such as immunizations and care for chronic problems, although it is not clear how much these new services are for adults and how much for children.

The RBC movement is clearly a major one.  Offering care in a different setting is similar to a new technology, and as such, deserves attention and evaluation.  The AAP is dedicated to protecting and promoting the health of children.  It is important for the AAP, therefore, to provide guidance to patients and to the nation on this new development. 

Because of the newness of this movement and the dearth of evaluative studies, no definitive judgement is possible at this time.  We can, however, describe the need that this movement has responded to, describe the settings and the approach of RBCs, and analyze what problems might arise, and what we see as the responsibilities of this new industry.  In doing so we will concentrate on children, and not delve into the implications of RBCs for adult health.

The Need

First, it is important to ask why RBCs have been initiated.  It would appear that RBCs have emerged both as a solution to a problem – lack of access to acute medical care – and from the lure of profit to commercial entities.

It is certainly true that patients with acute problems have had difficulties accessing primary care providers.  This is particularly true for adult patients, and indeed, RBCs were created initially to serve adults rather than children, because as adult primary care practices have focused on chronic disease, obtaining appointments even during regular office hours has often been difficult, and obtaining care out of hours even more so.  As a result, emergency departments (ED's) in hospitals now serve primarily non-emergency patients, waits are long, and prices are very high. 

By contrast to adult practices, pediatric practices do routinely serve patients with acute problems.  Virtually all pediatric private practices and clinics routinely make room for call-in appointments each day they are open for business.  Many are open on Saturdays, and most make provisions for out of hours telephone triage.  Many practices see patients on Sundays, some in evening hours, and increasingly practices provide extended hours care in mornings and evenings, and some accept walk-in patients.  It is true, however, that many practices present barriers to easy access, allowing telephone calls to pile up, requiring long waits in the clinic or office, and providing appointments at times inconvenient for patients. 

It can certainly happen, for instance, that if a child is sick during the night, parents are faced with the need to await the opening of the office, calling the office for an appointment, receiving one for later in the day, arranging emergency child care, leaving for work and then leaving from work to transport a child to the office and back, visiting the pharmacy, and then returning to work or not – all in service of an appointment that may well last all of five minutes.  Pediatric ED's are often poor alternatives, with long waits and high costs.  Thus, in some parts of the country and with some practice arrangements, just on a logistical basis, one can certainly understand the choice of a family to visit an RBC.

The Response

One of the strengths of the American economic system is the ability of commercial enterprises to respond to an opportunity for profit.  The gap between need and supply for acute care services has provided just such an opportunity.  RBC's solve an access problem when a home practice is closed, and sometimes even when it is open.  For the company that owns the RBC, the service not only can produce a profit directly in itself, but the colocation of medical services with pharmacy and other unrelated products can generate even more.  The commercial enterprises have reduced their costs by providing not physicians, but less-expensive Advanced Practice Nurses (APN) as providers, utilizing care algorithms for guidance, and apparently supplying physician guidance at a distance.  Since the main objective of RBCs is adult care, no specifically pediatric providers are generally utilized.

The Questions

While the American system provides innovation, what is not supplied automatically is quality evaluation.  Patients can judge availability and affordability and make other such general consumer judgements, but they cannot judge the scientific aspects of medical quality.  This, then, is the big question: is this innovative method of service provision of sufficiently high quality to be safe and effective for children? It is convenient, but is it an attractive hazard?

An associated question is this: even if basic quality were judged to be sufficient, how do RBCs integrate into the system of medical care?  Do RBCs comfortably integrate into the system of care, or do they further fragment care in an already fragmented system?  And are there unanticipated consequences that might be associated with the spread of RBCs?  For instance, by taking from practices the more acute cases which are also high-margin visits for practices, do they endanger the economic viability of primary care pediatric practices?  Finally, in envisioning the proper functioning of the health care system, the AAP and other organizations have endorsed the Patient Centered Medical Home (PCMH) as the ideal center of the system.  Is provision of care at RBC's consistent with the centrality of the PCMH?

The final question is, what is to be done?  Clearly, in some areas and for some patients, RBC's seem to be answering a perceived need for accessibility.  Should established medical organizations welcome and strengthen RBC's and work to bring them into the system?  Should established pediatric practices and clinics take on RBC's and compete?  How can the perceived need for accessibility be best met by our medical care system?

Quality of Care in RBC's

The most important current question in RBCs is: does the general quality of care for children pass the threshold where RBCs can be recommended for patients?  Despite great advances in quality measurement, this is not an easy question for any practice site.  Some aspects can be measured, especially stereotypical encounters such as immunization administration and sore throats, although even there we are dependent on accuracy of charting and subject to manipulations by savvy clinicians – that is, a clinician can easily make a diagnosis that he or she knows will call for an antibiotic if that is what they want to prescribe.  But many important aspects just cannot be measured – accuracy of diagnosis and pursuing occult diagnoses are important immeasurables, for instance – and determining an overall assessment for a practice is still well beyond us.  

Thus, determining how well RBC's actually function medically is a very difficult question.  If it were a question less important than the health of children, we could afford to wait and let experience decide.  The sometimes critical nature of health care, however, makes it important to arrive at some judgement.  Given that RBC's are very different medical entities than traditional ones, the burden of proof of safety and quality should be on the new entities themselves.  While we need to be open to innovation, safety should be the first consideration. 

In the original work on quality by Avedis Donabedian, he distinguished three levels of quality assessment: structure, process, and outcome.  In most American practice situations structure can tell us little, since virtually all practices and clinics have the requisite clinical equipment (blood pressure cuffs, basic lab equipment including rapid strep testing, etc.) and most pediatric practices and clinics have Board Certified pediatricians (or at least family practitioners) giving care, and they have what we could call medical environments, where medical standards predominate in an almost unspoken way, and where peer influence is medical.

In RBCs, however, basic structure is different.  Clinical equipment is probably up to par, but Board Certified medical personnel are not present.  In addition, RBCs operate in an environment isolated from medical personnel.  Instead, the immediate environment is retail, by definition.  Further, the RBC enterprise at large is sponsored by commercial entities that are not primarily health entities, as are hospitals or health care networks.  It is possible that this overall direction will have some effect on the RBCs.  Let us deal with those three questions now.

First, personnel.  Traditionally, medical care has been dispensed by physicians, and in the case of children, by pediatricians and sometimes by family physicians.  APNs and physicians' assistants have been introduced to the medical workplace in recent years with good results, mostly practicing in concert with physicians, and sometimes as a group independently.  It has been rare for single APNs and PA's to practice isolated by themselves.  Thus, the RBC model of APNs practicing away from close proximity to physicians, or at least other APNs, is new.

We do not know the hiring practices of RBCs.  What is the experience of the APNs they hire?  They almost never come from a pediatrics background, and family practice APNs have little training in pediatrics.  Are they experienced APNs who have practiced for years in an organized medical setting?  We know that APNs are not held to the same standards for continuous updating in pediatrics that licensed physicians and Board Certified pediatricians are held to.  We also do not know what oversight they receive – how constant and intent is oversight?

RBCs claim that the use of algorithms can ensure quality of care.  Has this been proved?  Is every encounter stereotypical, and thus falls within the purview of an algorithm?  What happens when a case does not fall there?  What are the back up arrangements for non-stereotypical and possibly serious cases, or just puzzling cases?  How quickly can an APN at an RBC contact someone more knowledgeable?  Are those connections in place for each RBC?  Who is the backup?

Primary care can be deceptive.  Everything is not “colds and sore throats.”  Who can identify a “simple illness?”  What appears to be a simple illness to a parent and a new APN might well be judged more serious by an experienced pediatrician.  Constant attention to possible problems is the stock in trade of the primary care pediatrician, and missing just one or two here and there might be acceptable in another pursuit, but not in children's health.

In short, the first and most important structural criteria for quality, personnel, is quite questionable for RBCs.

Second, medical environment.  In a medical environment, a medical ethic prevails.  Although unquantifiable, a medical ethic conditions actions of the participants.  Organizational theory tells us that the atmosphere of an organization determines much of participant behavior.  When medical personnel are placed in a non-medical organization, it would take a deep ethic for that personnel to have an ethic that prevails over the non-medical setting.  One could expect an experienced clinician with deep historical roots in the medical ethic to have his or her ethic prevail in an RBC environment.  It would be much more questionable if someone less experienced and less deeply rooted would have his or her ethic prevail in a retail outlet.  The APN in a retail outlet might be guided by algorithms, but the APN is also a person.  It is unlikely that the organizational structure offered by RBC's, where supervisory staff are not on site and are thinly spread, would be able to produce the same influence as one sees in a medical office. 

In many cases in medical practice, behaviors in a medical setting will be expected to improve with time, as the medical ethic takes effect.  Theory tells us that with time, behaviors in a retail setting would tend to bend toward the retail ethic rather than the medical ethic.  It is true that retail pharmacies have licensed pharmacists in place, and that the APNs will frequently be associated in a space close to them.  It is questionable, however, if they will be lending the same attitudinal support that a physician would in an organized practice setting.

Third, larger retail organization.  The major goal of a large retail pharmacy chain is to be profitable for their shareholders.  This is especially true in the modern era, as the associated goals of corporations to serve their community and serve the country have deteriorated.  If this is the larger goal, one would expect that providing high quality health care would be a constraint rather than a goal. 

What is the commitment to quality of care of the RBCs?  Do they have rigorous and continuous oversight of their care?  We do not know.  Since quality would be a constraint rather than a goal, we can well imagine that while profitability is continually assessed, quality of care is not.

It might be useful to consider a situation where, somehow, quality of care has become questionable in one of the RBCs.   What would be the response of the organization to that situation?  What if it proved difficult to replace the personnel?  What would be the response of the parent organization if the RBC were profitable?  Would they close the RBC?  Or would they let it continue while they looked for a replacement, or had the APN undergo retraining?

The RBC advocates contend that the quality of RBC care is high.  They point to a few studies that have shown that in stereotypical situations APN's in RBCs have performed as well as or better than pediatricians in usual practice situations.  While this might be reassuring, it is not determinative.  As mentioned above, such studies will of necessity be samplings that are record-based only, not based on actual in person assessment, nor widely based on actual situations that arise in their inevitable variety, and not based on follow up of many patients.

It is disquieting that the RBCs have offered the feedback of patients as evidence of quality.  While patient satisfaction is an important component of medical quality, “being served promptly” does not equate with “being diagnosed and treated appropriately.”  The fact that the RBCs would offer such inadequate responses casts further doubt on their motivation; these contentions smack strongly of the very commercial ethic that medicine should deplore.  Perhaps more telling are the numerous anecdotal reports of pediatricians who have had experiences with their patients being treated at RBCs.  While not up to the standards of scientific study, of course, these reports are often alarming in their deviation from good quality care. 

Because of the novelty of the setting, the burden of proof that quality is high and provision of care is safe needs to lie with the proponents and ownership of these centers.  Moreover, the assessments need to be done by disinterested parties.  Such assessments have not been offered. 

In sum, in the important question of quality of care, we have strong reservations about RBCs.


Relationship of RBC's to the System of Care

A chronic problem of the American health care system has been fragmentation.  In response to that problem, and in order to provide for a more patient-centered approach to care, the Patient Centered Medical Home was conceived.  The PCMH has become all the more important as improvements in medical care have produced ever more tests, ever more procedures, and ever more diagnoses.  There needs to be a center, and the PCMH is it.

The question is, to what extent do RBCs impede the mission of the PCMH?  And if the PCMH mission is impaired, is that balanced by a compensating gain in accessibility for the patient, or in cost for the system?

Continuity of care should reside in the PCMH.  Seeing the same practitioners has value in psychological terms and in medical terms.  Each patient is a distinct organism, and understanding the particulars of that individual can best be accomplished in a longitudinal manner.  The medical history of the patient can be important and is not available at an RBC.  Seeing a patient for an acute visit can trigger off a perception in the child's personal clinician that would not be possible in a clinician unfamiliar with the patient and the family.  Just as emergency room shopping is a well recognized feature of adult care, RBC shopping for a chronic behavioral illness can be just as possible and as dangerous in a pediatric patient.  Continuity is important.

Another systematic concern would be financial viability of the PCMH.  The PCMH has multiple functions, and financing all of them can be difficult.  In a primary care practice some of the highest profit margins are obtained in routine illness visits.  Financially, these visits are the “cream” that the RBCs are skimming off the top.  Primary care practices are usually the most precarious parts of the health care system, and RBCs can be compromising the viability of the PCMH.  On the other hand, cross-subsidizing (having acute visits subsidize some of the costs of the other PCMH services) might not be the only way for financing the PCMH.  It is difficult to think, however, that many payers will increase their payments to the PCMH for services other than acute visits in an effort to keep the PCMH viable.

On the other hand, aside from the severe quality considerations we have listed above, if RBCs can provide superior access for patients, this should be honored.  It is technically feasible for RBCs to communicate with practices so that the visits can be logged in the home record.  If they would wish to do so, practices could establish relationships with RBCs to give them backup and even real time advice.
The case for doing so, however, would be tenuous, even with acute visits.  When it comes to providing immunizations and other services, however, it is hard to think how this would ever constitute acceptable pediatric care.  Aside from the obvious impossibility of record keeping and assuring that the proper immunizations were administered, and aside from the lack of constant attention to immunization changes and standards, there is no way that an RBC could provide chronic care to children in any acceptable manner. 

There are many reasons to think that the best care can be provided for children at their PCMH, if one is available to them.  Quality of care would no doubt be best at the PCMH, and fragmentation minimized.  Special arrangements could minimize fragmentation at times if RBCs were utilized, but the net result would be far from optimal.

Costs

The cost of care at RBCs is said to be lower than at practices and clinics, although no studies have defined this exactly.  The posted prices are sometimes not indicative of final cost when tests and prescriptions are added in.  Nonetheless, if RBCs indeed lower the cost of care, this would be an important consideration.  Unfortunately, we do not know much about the effect of RBCs on the cost of care.  Because acute care is not the major source of high costs, if there were positive effects, we would expect them to be minor.  A recent study found that costs were actually higher with RBCs because they induced many visits that would under other circumstances simply be foregone. 

Even if there is no effect on the overall cost of care, the impact on individuals is still important.  If a patient can pay less for an episode of care by visiting an RBC, and if quality of care would be acceptable, that would make substituting an RBC visit for a practice visit acceptable, and something that practices and clinics would have to contend with.

The Responsibilities of RBCs

RBCs are new institutions.  They bring a new way of providing care and in so doing, violate many of the quality and systemic standards that have been accepted in medicine for a long time.  In making these changes, it is incumbent on the RBCs to ensure that their services are indeed worthwhile.  If we were not talking about children's health care, if we were talking about new toasters or televisions or music apps, then the market would be allowed to speak for itself.  But children's health is different.

The great market advocate Milton Friedman once speculated if the FAA were necessary.  Couldn't the industry be trusted to police itself, to make safety inspections of its airplanes without governmental interference?  A few plane crashes, after all, would put a company out of business.  Freedom would also allow passengers to choose a cheaper airline that they knew skimped on safety inspections to save money.  Even Milton Friedman, however, came to endorse the role of the government in prospectively ensuring safety as opposed to the market in the case of airline safety.

We would assert that children's health is more akin to airlines than to toasters.  Safety and high quality are important.  Thus, it is incumbent on the innovators, the RBCs, to prove its high quality and safety.  Studies need to be conducted by impartial parties.  The RBCs need to present their plans and operations in detail, without regard to company secrets, to convince the public and the medical profession that its operations are proper.  If they can surmount the quality problem, the RBCs need to ensure that care is only minimally fragmented.

The Need for Innovation

Despite the many negatives for RBCs sketched in this paper, it is important that medical care organization not be stuck in current arrangements.  Competition is a good thing.  It is important for current practices and clinics to understand deeply the barriers they put up between them and their patients. 

What have RBCs supplied that practices and clinics have not?  Clearly, easy availability is very important to modern families who generally have busy lives.  Have practices and clinics sufficiently adjusted to that fact?  Do they understand the need to adjust hours and appointment procedures to the families' needs?  Do they feel the urgency to adjust?

Most people respond to threats more rapidly than to suggestions.  The best results from the RBC movement would be for practices and clinics to adopt easy appointment procedures, drop-in times at early and late hours, and extended hours for both acute and routine visits, including both weekdays and weekends.  Another good result would be for more clinics and practices to understand the need to become PCMHs, in fact even if not formally accredited.  Some practices and clinics might want to compete closer to the RBC turf, and to establish RBC-like clinics close to patients but tied in directly to the personnel and EMRs of the home practice.  Many other accommodations and innovations would be possible.

It would be wrong to reject RBCs simply because they were a threat to the usual way of doing business.  It would be right, on the other hand, to reject them as they currently exist for many of the reasons stated in this position paper.

We frankly believe that the quality barriers are too high for RBCs to be viable purveyors of care to children.  Nonetheless, innovation is to be welcomed, and not to be rejected just because it is new, or just because it is uncomfortable for existing institutions.  The best response from a system is to compete, and to find a way to supply the same services that the innovators are providing, or better.