Quick Clinic NPs: Neos in the Health Care Matrix?
July 18, 2004 -- Today the New York Times business section ran a substantial piece by Michelle Andrews about the growth of nurse practitioner-staffed "quick clinics" that operate in large retailers and provide faster, cheaper preventative care and treatment for a range of common illnesses. The article, "Next to the Express Checkout, Express Medical Care," provides a basically fair description of the work of the clinics, but many elements are likely to leave readers with inaccurate and damaging impressions about nurse practitioners.
The story describes the rise of quick clinics, which have names like "MinuteClinic" and "FastCare," in large discount stores and supermarkets in a number of states. The clinics reportedly aim to treat a limited range of relatively simple ailments, such as strep throat, sinus and ear infections, and seasonal allergies. They also provide vaccinations and screenings for blood pressure and cholesterol problems. The focus is on saving people time; waiting time is minimal compared to the long waits at primary care practices and emergency departments. But the clinics also appear to be far cheaper than conventional primary care. The piece clearly respects the clinics' business model, carefully explaining the niche they are filling, and noting that MinuteClinic has had 142,000 patient visits since its 1999 founding, and that it is opening a number of new locations. The story also appears to reflect some respect for the work of the NPs. It describes the visits of a couple of apparently satisfied patients to MinuteClinics in Minnesota. And it notes that NPs "typically have a four-year degree and a two-year master's degree in nursing," though from this phrasing many readers will not understand that the undergraduate degree was also in nursing, which will likely lead them to undervalue the NPs' health care training.
The story has other misleading or condescending elements. First, there are the expert comments of the physicians. Andrews notes that, though the clinics have physicians available by phone during business hours, some physicians caution that the clinics "should not take the place of regular visits to a primary care doctor." We don't doubt that the physicians Andrews consulted used only the term "doctor," but her sentence does not tell readers that tens of thousands of nurse practitioners provide a full range of conventional primary care services; they are not just "quick clinic" specialists. Since NPs are themselves vital primary care providers, it seems very unlikely that an NP would argue that the quick clinics should completely "take the place" of regular primary care visits. But the failure to say so suggests to readers that they might. J. Brian Hancock, president of the American College of Emergency Physicians, claims that at quick clinics "you're depending on the patient to know what they have before they get there." While Hancock allows that the clinics might be OK for a "quick fix," the story notes that he believes they are no substitute for "a continuing relationship with a doctor." The piece also states that Michael O. Fleming, president of the American Academy of Family Physicians, believes that "[r]ecurring problems need to be evaluated by a physician," because as Fleming says, "[p]hysicians have significantly more training, and that training is to look for early signs of complications." The story does provide some balance for these anti-nurse views by quoting Jan Towers, director of health policy for the American Academy of Nurse Practitioners, who says that NPs are "certainly qualified" to staff quick clinics, and that they are trained to diagnose different diseases and to know what to prescribe for them. The piece also notes that MinuteClinic's computer system flags patients who come in repeatedly for the same problem, describing the case of a 5-year-old Minnesota boy who was referred out after his fourth strep test; eventually his tonsils were removed.
But this is not enough. Once again, nothing here tells readers that nurse practitioners are conventional primary care providers; the equation of full primary care with physicians is relentless. Moreover, since the quoted physicians are so eager to push the view that nurse practitioners are less qualified to provide primary care, Andrews' readers might have appreciated hearing about the growing body of research showing that NP care is in fact at least as good as the care of physicians. Hancock's quotes in particular may suggest to readers that NPs are qualified only to diagnose the limited list of ailments the clinics focus on, an idea that is ludicrous in light of NPs' six years of health care training. In this respect, even the Towers quote is weak, since by itself it also may suggest to some that NPs are qualified only to staff quick clinics. Of course it's important to ensure that patients understand the scope of the care the clinics can provide. But nurse practitioners are highly skilled, licensed professionals, and the article supplies no evidence as to adverse effects because quick clinic NPs have missed diagnoses or patients have relied unduly on them. Indeed, it seems reasonable to expect that highly skilled NPs would (just like primary care physicians) be likely to catch a wide range of potentially serious problems in the course of even their quick clinic diagnoses, and refer the patients accordingly, potentially saving countless lives--just as primary care physicians and NPs do every day as part of their conventional practices.
Another problem in the story is the suggestion that the clinics' care is safer because there are software systems telling the NPs what to do, as was implied in the case of the boy who had his tonsils removed. The piece describes the $15 million software system MinuteClinics NPs use. This software "incorporates clinical guidelines" and doesn't let NPs prescribe antibiotics "without a positive test result." Obviously this wrongly suggests that NPs are not qualified to diagnose and treat without some software program guiding them. But the real screamer is the antibiotic comment, which without any further explanation suggests that those zany NPs would be tossing handfulls of antibiotics down the aisles of Target if there wasn't some system to rein them in. We are aware of no support (and Andrews supplies none) for the notion that NPs are any more likely than physicians to prescribe antibiotics without adequate cause. Overprescription of antibiotics is a well-known public health problem, as it encourages antibiotic resistance. But as with the scope of care point above, we doubt the article would have taken such a paternalistic tone if the clinics were staffed by physicians.
At another point, to support the idea that some clinics allow NPs "more autonomy," Andrews quotes a quick clinic executive as saying that a patient with strep throat may be "treated with some variation depending on where the nurse practitioner was trained." What does that mean? That some NPs will provide conventional care, and others Martian voodoo? If it simply means that there is some variation in practice depending on a practitioner's background, isn't that equally true of physicians? It's hard to say what readers will take away from this, except that it's unlikely to be an accurate sense of NP care.
The piece also suffers from an astonishing omission. Though it has quotes from quick clinic executives, national experts and patients, it fails to include a single quote from any of the nurse practitioners who are at the center of the store--er, story.
On the whole, the piece seems to reflect some condescension for the basic services the clinics provide. But vaccinations and basic screenings have saved millions of lives around the world in recent decades. Moreover, the clinics' speed and affordability may mean that many patients are receiving vital care that they would not otherwise have received at all in the nation's current inequitable health care environment. Whatever the quick clinics' limits, dismissing their care as merely a "quick fix" is, at best, uninformed. The rise of clinics can be viewed as not just a clever business initiative, but a promising new basic care model in an often harsh health system.
See Michelle Andrews' article "Next to the Express Checkout, Express Medical Care" in the July 18, 2004 edition of the New York Times.