The No-Fact Zone
Bill O'Reilly and Ezekiel Emanuel face off on quick clinic NPs
March 4, 2014 -- In a segment on tonight's edition of the Fox News show The O'Reilly Factor, host Bill O'Reilly criticized the Affordable Care Act (ACA or Obamacare) for promoting more use of quick clinics. O'Reilly stated that the clinics did not have any physicians, but were staffed by "physician's assistants and nurse practitioners and things like that." (Things like that?) Guest Ezekiel Emanuel, a physician who is one of the designers of the ACA, noted correctly that physicians are not required for "every part of your health care." O'Reilly agreed, but said that "if I want a strep throat diagnosis, I don't want Lenny who just came out of the community college." Emanuel responded: "Excuse me, but those are nurse practitioners, it's not Lenny out of a community college, and it is just putting a swab back there, and getting a strep throat assessment." We thank Emanuel for making clear that nurse practitioners (NPs) have more education than community college and that physicians are not required for all aspects of health care. It would have been even better for viewers to hear that NPs typically have graduate degrees in nursing and that they excel not just at care that people may see as straightforward (like a strep throat diagnosis) but comprehensive primary care, which many NPs give in their independent health practices. Emanuel was arguing that the growth of quick clinic health care was no problem in part because it's straightforward and therefore does not require a physician. But in fact, decades of research shows that the care of NPs and other advanced practice nurses is at least as effective as the care of physicians even for health issues that are not so straightforward. In any case, we urge Mr. O'Reilly to avoid further misstatements about the value of nursing care.
The exchange between O'Reilly and Emanuel came during a six-minute segment called "American Doctors and Obamacare." O'Reilly argued that some recent polling showed that many physicians don't like the ACA, so the physicians were going to opt out of the system and cause it to fail. Emanuel pointed out that that will not happen because the ACA is an insurance program and relatively few physicians can avoid accepting insurance. O'Reilly took another tack, suggesting that the law relies too much on non-physician providers.
O'Reilly: When I travel around . . . I see these clinics open up, and I'm sure you do too, the health care clinics, and they're like walk-in clinics, you get something the matter, come on in. And they're staffed by physician's assistants and nurse practitioners and things like that. I think that's where this Affordable Health Care Act is going, into that kind of treatment. Am I wrong?
Emanuel: That's going to be one part of a complex part of the health care system. So if your kid has a sore throat and you want to find out if it's strep throat, or your kid has what appears to be an ear infection, and you want to find out if it's otitis media, you really don't need to go to the pediatrician. You can go to these clinics, because of electronic records which are now being widely used because of the health care reform, they'll send it to your doctor, they'll send it to your health system, and so we'll have a much more seamless operation. In fact CVS is expanding those kind of clinics, Walmart is expanding--
O'Reilly: They're all getting into that business, but there aren't any doctors. They're not doctors.
Emanuel: Well, you don't need a doctor for every part of your health care.
O'Reilly: You don't need a doctor for everything, but if I want a strep throat diagnosis, I don't want Lenny who just came out of the community college, I mean, you know--
Emanuel: Excuse me, but those are nurse practitioners, it's not Lenny out of a community college, and it is just putting a swab back there, and getting a strep throat assessment.
O'Reilly moved on to suggest that the ACA's electronic record keeping was insecure, and Emanuel disagreed, noting that there had been no breaches of privacy to date.
Things like that
The most obvious problem was O'Reilly's suggestion that care givers at quick clinics are "Lenny who just came out of the community college," which came on the heels of his observation that the clinics had no physicians but were staffed by physician's assistants and NPs and "things like that." The clear message was that nurse practitioners and physician's assistants are inferior practitioners who do not have bachelor's degrees. In fact, nurse practitioners typically have at least bachelor of science and master of science degrees in nursing. And an increasing number have the four-year doctorate of nursing practice, which is slated to become the standard entry-level NP degree in 2015. Physician's assistants have masters degrees in health science. And decades of research shows that the care of NPs and other advanced practice nurses (APRNs) is at least as good as physician care on a wide range of critical health measures, including acute and chronic care.
Emanuel's responses to O'Reilly's comments were good as far as they went. His "excuse me" was very powerful rhetorically--he is clearly adept at this difficult medium--and of course he had already made clear that physicians are not required for every aspect of health care. Ideally he might have quickly noted what education NPs do have, but we understand that there are limits to what can be conveyed in this kind of interaction. We were a little more disappointed with his additional note that getting a strep throat diagnosis was no big deal. That may have been an effective short response to O'Reilly's point, but without more information about NP care it suggests that NPs are fine for quick clinic care because it's not that difficult. And Emanuel's earlier description of quick clinic care was similarly presented in terms of things for which you "don't need to go to the pediatrician," implying that some things would require a pediatrician, as opposed to a pediatric nurse practitioner. In fact, as the research shows, NPs are adept at the full range of primary care, and many provide it in independent primary care practices. Perhaps Emanuel's responses were savvy defenses of the health reform he was discussing, but they were not adequate defenses of APRNs in general. In this respect, they were reminiscent of the time when quick clinics first appeared, when quick clinic company executives were eager to stress how limited the clinics' care was and how closely the clinic staff worked with physicians.
We do wonder why more ACA critics have not seized upon the reform law's encouragement of expanded APRN practice. No doubt they could find eager support from some representatives of organized medicine. And most of the public continues to extend extraordinary deference to physicians, in no small part because of media products like this one. It may be that those who have looked at the law closely enough understand that the critique is double-edged, since APRN care is generally less expensive, with more focus on prevention and health maintenance, all of which runs counter to the claim that the ACA will increase health care costs. Or it may be simply that the role of APRNs, like that of nurses generally, remains mostly under the radar.
In any case, we thank Emanuel for his basic defense of NPs in the quick clinic context and hope he will provide more complete information in the future when possible. We urge O'Reilly to apologize for his inaccurate statements about NP care and to avoid such statements in the future.
See the 6-minute segment of The O'Reilly Factor (Fox News Channel) called "American Doctors and Obamacare." Scroll forward to about 2:40 for the most relevant part.