Family Practice Vol. 19, No. 2, 202-206
© Oxford University Press 2002
Original Paper |
Walk-in clinics: patient expectations and family physician availability
Centre for Studies in Family Medicine, Department of Family Medicine, The University of Western Ontario, London, Ontario,
a Department of Community and Family Medicine, Duke University, Durham, North Carolina, USA,
b Department of Health Administration, University of Toronto, Toronto, Ontario,
c Division of Community Health, Memorial University of Newfoundland, St John's, Newfoundland and
d North Hamilton Community Health Centre, McMaster University, Hamilton, Ontario, Canada.
Dr Judith Belle Brown, PhD, Centre for Studies in Family Medicine, 100 Collip Circle, Suite 245, London, Ontario, N6G 4X8 Canada.
JB Brown, LM Sangster, T Østbye, JM Barnsley, M Mathews and G Ogilvie. Walk-in clinics: patient expectations and family physician availability. Family Practice 2002; 19: 202–206.
Received 20 February 2001; Revised 26 July 2001; Accepted 1 November 2001.
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Abstract |
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Background. For over two decades, there has been controversy over the role and impact of walk-in clinics on primary health care. This study evaluates the providers' perspective on this topic.
Objective. The purpose of this qualitative study was to explore the perceptions and experiences of family physicians, emergency physicians and walk-in clinic physicians regarding the impact of walk-in clinics on Ontario's health care system.
Methods. The qualitative method of focus groups was used in this study. There were nine focus groups, each consisting of 4–9 participants, with a total of 63 physicians. The different practitioners (family physicians, emergency physicians, walk-in clinic physicians) attended separate focus groups. The focus groups explored the physicians' perceptions and experiences regarding the role and impact of walk-in clinics on Ontario's health care system. The focus groups were audio-taped and transcribed verbatim. The qualitative data analysis program NUD*IST was used to organize the data during the sequential thematic analysis.
Results. Factors contributing to the growth and evolution of walk-in clinics in Ontario were identified. These included a perceived increase in patients' expectations for convenient health care and a perceived decrease in the availability of family physicians. These factors created a gap in primary care which was filled by walk-in clinics.
Conclusions. Participants' recommendations for narrowing this gap included an increase in both physician and patient accountability and changes to the current structure of primary health care delivery. These recommendations would either integrate walk-in clinics into the health care system or result in their elimination.
Keywords. Focus groups, health services research, primary care, walk-in clinics.
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Introduction |
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For almost two decades, in North America, there has been controversy regarding the impact of walk-in clinics on the delivery of primary care services.1–9 Critics of walk-in clinics have highlighted issues of duplication and unnecessary competition.1,7,8 The loss of continuity of care, a core tenet of family practice, has been a major concern.1,7,8 In contrast, proponents of walk-in clinics have emphasized the convenience they offer to highly mobile consumers faced with multiple work and family demands.6,9 Furthermore, these authors argue that walk-in clinics decrease the burden on emergency departments by providing non-urgent care.6,9 In addition, walk-in clinics are open outside conventional office hours when family physicians may not be available.6,9
Prior studies examining the impact of walk-in clinics on primary care services have reported the profiles of patients who use these clinics and their level of satisfaction with the available services.6,7,10,11 Yet, the views of practitioners actively delivering primary health care services have not been fully explored. The purpose of this qualitative study was to explore the perceptions and experiences of primary care physicians, including family physicians, emergency physicians and walk-in clinic physicians, regarding the impact of walk-in clinics on primary care services. This study was part of a 3-year multicomponent, multicentre study called ‘The Role and Impact of Walk-in Clinics in Ontario’. The overall project was a multimethod study employing both qualitative and quantitative methods. The qualitative method of focus groups spearheaded the project and the findings offered guidance and direction to the surveys and observational studies that followed. The overall objective of the project was to examine the role of walk-in clinics in the delivery of primary health care in Ontario and subsequently their impact on the Ontario health care system. Ethics approval was obtained from the Review Boards of all three participating institutions: The University of Toronto, The University of Western Ontario and McMaster University.
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Methods |
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The study reported in this paper used the qualitative method of focus groups.12 Focus groups have been used extensively in the primary care setting to explore patients' and providers' perceptions and opinions of services and programs.13–16 Nine focus groups were conducted in Hamilton, London and Toronto, Ontario, Canada in the Spring of 1997. Three focus groups were held in each city: one focus group with physicians who worked primarily in emergency departments; one with physicians from walk-in clinics; and one with family practitioners.
Focus group participants
Local investigators in each city recruited their focus group participants. Thus, the method of recruitment varied somewhat from city to city, with some participants identified through family medicine and emergency medicine departmental mailing lists, and some identified by key opinion leaders within their discipline. The objective was to identify physicians who would reflect a variety of opinions and experiences from each site during the focus groups.
A total of 63 participants (48 male and 15 female) attended the focus groups, with 4–9 participants per group. Over 87% of the participants had graduated from Canadian medical schools and 62% had graduated after 1980. While the intent was to have homogeneous groups (i.e. only walk-in clinic physicians in one group), some participants practised in more than one primary care setting. For example, some physicians had first practised in a walk-in clinic setting, which later evolved into a family practice; these participants provided two perspectives on the study questions.
Focus group conduct
One of the investigators from each site assumed the role of moderator. A research associate (MM), present during all the focus groups, recorded field notes and provided a consistent link between the sites. The focus groups, which ranged in length from 45 minutes to 2 hours, were audio-taped and transcribed verbatim.
Analysis
The researchers read the transcripts independently, initially looking for key words and emerging themes. After each focus group, a conference call was held during which researchers compared and combined their independent analyses. This process allowed for the exploration, expansion and testing of themes in subsequent focus groups. An extensive list of key words and themes was maintained and revised throughout this process, resulting in a final analysis template which allowed the researchers to organize and code the data accordingly. All the transcripts were coded using the analysis template and entered into a software program designed to assist in the organization and management of qualitative data. At this stage of the analysis, three of the researchers (JBB, LMS and TO) conducted a secondary analysis of the data examining similarities and differences across and within the focus groups and the relationships among the identified themes. Several iterations of the findings were circulated among the research team for clarification and consensus prior to finalization.
Because some participants were working in both walk-in clinics and family practice, attention was given to which ‘hat they were wearing’ as they contributed during the focus groups. In order to identify the specific role of speakers, the investigators compared the transcribed comments with the field notes collected during the focus groups to examine the context of the individual speakers.
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Results |
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The analysis of the focus group data identified three overarching themes: (i) variability in the perception of the role and function of walk-in clinics; (ii) the tension existing in primary care services due to factors such as duplication and competition; and (iii) factors contributing to the evolution of walk-in clinics in Ontario's health care system. Focus group participants' perspective on this third theme are described in detail in this paper. Participants viewed the evolution of walk-in clinics in Ontario's health care system as being influenced primarily by changes in two areas: a perceived increase in patients' expectations for convenient health care; and a perceived decrease in the availability of family physicians.
Participants described patient convenience as easily accessible health care: "Bottom line is it's a service. People want a convenient service. They go, it's close, it's at the time they choose." The participants attributed this mindset of convenience to a societal expectation that health care should be as convenient as fast food outlets. Several focus groups used McDonald's as an analogy:
"I think one of the other issues with a walk-in clinic patient is the whole urban McDonald's mentality, the doc in the box is there. ‘Now is the time when I want the service. [I may have been sick] for two weeks but now is the time I want my Big Mac and fries so I’m going to walk into the walk-in clinic and get it now.'"
Participants discussed the discrepancy between patients' expectations and the obligation of the system to provide convenient care. "One of the big questions is what the consumer expects and what the consumer has a right to expect from the system." Yet, participants also acknowledged how societal changes in family structure required that health care services be more responsive to the needs of working parents.
"If [you] look at the number of families now that have got 2 working parents, whereas in the 60's when Mom was always at home and Johnny got sick, well then, call the doctor and take Johnny to the doctor at 2 o'clock in the afternoon. But now Mom's working days and Dad's working evenings because they're both working shift-work and they've got to hold down the mortgage."
Furthermore, some participants viewed limited social support and lack of extended family as contributing to patients' use of walk-in clinics ". . . families do not have that extended support . . . There is simply no place else that they can turn to for simple things and they panic".
During several focus groups, participants also identified specific patient attitudes that augmented the expectation for convenient health care. These included a disregard for continuity of care and a desire for anonymity. Participants commented on how a growing number of patients appeared to downplay the importance of continuity in their health care. "They've lost the concept of continuity of care." Seeking health care that protected their anonymity was another patient attitude attributed to patients' attendance at walk-in clinics. "They like someplace anonymous to go."
The perceived decrease in family physician availability was the second key area influencing the evolution of walk-in clinics in Ontario. All the focus groups shared the belief that family physicians had limited their availability to patients, thus creating a niche for walk-in clinics.
"Traditionally family doctors always provided 24-hour-a-day coverage but in more recent years there are people out there that do their thing and go home. I think that's what really created the need for the walk-in clinics in the first place."
Participants offered two reasons why family physician availability had declined: family physicians' desire for a more balanced lifestyle; and financial constraints. In the focus groups composed of family physicians, there was extensive discussion of the desire for a more balanced lifestyle. "I mean you have to have your own personal life and we fit that in." The focus groups composed of walk-in clinic and emergency physicians also emphasized changes in physician lifestyle as contributing to the evolution of walk-in clinics.
"People are much more assertive about how they want to spend their life, and want to put strict guidelines on ‘Here is the time I’m working and when that's done, I'm done. And I'm not willing to sacrifice the rest of my lifestyle,' and that's why walk-in clinics exist."
With physicians placing more emphasis on a balanced lifestyle, the current financial incentives for providing on-call services were not substantial enough to motivate family physicians to maintain 24 hour availability. Furthermore, with the establishment of walk-in clinics: "It became entirely worthless to be on call because all you got were drug repeats and the difficult patients trying to get prescriptions out of you." Participants were also confused over family physicians' responsibility in providing 24 hour care and to what extent deputization was allowed. Some participants commented on how completely booked appointment schedules, fuelled in part by a desire for financial stability, contributed to a lack of family physician availability.
"I think in a family practice, if you want to provide full patient service you have to provide that sort of short notice availability. I think a lot of family physicians are to the point now where that's not necessarily convenient. If you're fully booked a week in advance then you've got guaranteed income. You know when your hours are going to be and there's no uncertainty involved."
Finally, the current social and political milieu was perceived as influencing the decline in family physician availability.
"I think that one of the reasons as [family] physicians when they feel a little abused and used by the system, under appreciated, and we've gone through a lot of political and social kind of alienation, and I think it results in people who think they would like to work 9–5, Monday–Friday and the rest of the time is theirs."
Participants felt that the perceived increase in patient expectations for convenient health care and the perceived decrease in family physician availability contributed to a gap in the delivery of primary care services. "There's a gap between emergency services and the primary care services and that's what the walk-in clinics have been filling up until now." Walk-in clinic participants viewed their services as filling the gap left by other primary care providers and believed they provided expedient care that met patients' expectations for convenience.
"I think we give the patients pretty good service in terms of not leaving the child waiting an extra day until they can see the family doctor and not leaving the patient sitting in emergency for a long time for a minor laceration which obviously is not a priority in the emergency department."
Participants believed that the multiple factors which had contributed to the evolution of walk-in clinics would remain. They felt patients' expectations for convenience would undoubtedly continue. "Walk-in clinics provide a sense of convenience . . . There certainly is a market for that kind of access that I don't think is going to disappear." Also, factors such as family structure, social support and financial concerns would continue to contribute to the need for convenient access to medical care. Similarly, participants felt that physicians' desire for a balanced lifestyle would persist. Until reimbursement issues for primary care physicians were clarified, the financial incentive to provide 24 hour availability would also remain in question.
However, all the groups provided suggestions on how to close or at least narrow the gap. One key area of potential change was increasing patient and physician accountability.
"There's no accountability for patients and no accountability for doctors . . . There's absolutely no reason that a patient can't go and see 100 doctors a day and there's no reason a doctor can't see 100 patients a day . . . So until you change fundamental things, make patients and physicians both accountable, nothing's going to change. The walk-in clinics are still going to do what they do because that's how they're surviving. That's why there's one on every corner, because they can do it. The patients know they can do it too."
Participants also endorsed a reorganization of primary health care services. Some indicated that walk-in clinics should be integrated into the health care system. "Walk-in clinics or after hours might be reasonable, provided they're integrated somehow into the health care system, into some form of primary care. Not willy-nilly, here, there, everywhere." Another recommendation that would integrate walk-in clinics would be the establishment of urgent care centres "that are prepared and equipped to deal with the things that are not quite life-threatening emergencies but fairly emergent in nature". In contrast, narrowing the gap through the extension of family physician and emergency services potentially could eliminate the need for walk-in clinics.
"I think the ideal solution would be to extend one or the other into that gap to fill it as opposed to having these entrepreneurial operations popping up to fill the need. Either having the primary care physicians get together in groups to provide some sort of service on their own or the alternative would be the emergency department."
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Discussion |
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Historically, family practice and emergency medicine covered the spectrum of primary medical care services in Canada. Our participants described how a gap had been created between these two traditional forms of primary medical care through a perceived increase in patient expectations for convenient health care and a perceived decrease in family physician availability. Participants admonished patients for their ‘McMedicine mindset’ reflected by demands for convenient and immediate care. Participants acknowledged that lifestyle, time and money influenced patients' decisions to use walk-in clinics. However, participants suggested that patients' demands for convenience perpetuated walk-in clinic utilization. Furthermore, participants perceived the reduction in physician availability as also fuelling consumers' use of walk-in clinics. Our study findings suggest that this reduced availability may be the result of the number of hours worked by physicians or could be attributed to how family physicians schedule their appointments.
More than a decade ago, the issues of family physician availability and patient convenience were documented as the main reasons for walk-in clinic utilization.6 Previous studies have also indicated that patients used walk-in clinics because they perceived their family physician as unavailable.6,7,11 What remains to be established is whether these perceptions are supported by empirical evidence. The College of Family Physicians of Canada (CFPC) National Family Physician survey, Ontario Regional Report described the average number of hours worked per week (including on-call) by family physicians in Ontario as 74.6 hours.17 Furthermore, 75.9% of family physicians were reported as participating in on-call activities.17 In addition, Bass and colleagues18 reported that family physicians, in their specific region of study, were providing more patient care time in 1994 compared with the previous 20 years. The results of both these studies could be interpreted as reasonable accessibility to family physicians.
Szafran and Bell's11 study in 2000 reported that 52.8% of patients did not even attempt to contact their family physician's office before going to a walk-in clinic. They also found that 43% of patients had attended walk-in clinics on weekdays between 9 a.m. and 5 p.m. when their family physician had office hours and, at least in theory, was available to provide care. Findings such as these raise questions of what constitutes reasonable physician availability and to what extent patients' desire for convenience should dictate physician services.
Patient convenience and family physician availability are inextricably linked. Our study participants recommended increasing physician and patient accountability in order to alter these factors. Furthermore, it became apparent that patients and physicians were experiencing similar societal pressures. Physicians were striving to balance their work life with their personal life, expecting both a reasonable lifestyle and a viable income. Similarly, patients were seeking convenient and available medical care that did not infringe on their work day and result in financial hardship. Thus specific societal forces, including lifestyle, time and money, were mediating factors for both physicians and patients. Acknowledging and addressing these societal factors will be important steps for health planners and policy makers to consider as the delivery of primary health care in Ontario evolves.
Undisputed in the focus groups was how walk-in clinics had filled the existing gap in primary care services in these urban centres. Participants recommended changes to primary care delivery that would either integrate walk-in clinics into the primary health care system or eliminate walk-in clinics through the expansion of family physician and emergency care services. Ultimately, their recommendations would alter the current existence of walk-in clinics.
Limitations
This study was conducted in three urban centres located in Southwestern and Central Ontario, thus limiting the transferability of our findings. Also, at the time of participant recruitment, we were not aware that some participants had dual affiliations (i.e. walk-in clinic and family practice). Consequently, their contributions to the focus group discussion varied according to the ‘hat they were wearing’. While this presented a challenge in the analysis, it also reflected the variability, observed in the focus groups. Therefore, this may be viewed as a strength rather than a limitation in that it generated richer and more varied perspectives as well as a more dynamic interchange among the participants. This study only explored the views and opinions of physicians, thus a qualitative study with patients including both users and non-users of walk-in clinics may provide further insights.
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Conclusion |
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Participants identified two major factors, an increase in patient expectations for convenient health care and a decrease in family physician availability, as contributing to a gap in primary care. Walk-in clinics had, to a certain extent, filled this gap. Although it is difficult to determine the extent to which these two factors contributed to the gap in primary care services, it does appear that the perceived impact of these two factors has encouraged and perpetuated the use of walk-in clinics. Participants recommended increasing both physician and patient accountability and changing the current structure of primary care delivery.
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Acknowledgments |
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The authors wish to acknowledge the contributions of the other co-investigators. The study was funded by Physician Services Incorporated (PSI) Foundation. The conclusions are those of the authors, and no endorsement by PSI is intended or inferred.
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References |
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