"Is 'Quick' Enough?"
January 16, 2007 -- Today The Washington Post published another in a long line of major media pieces about the growth of retail-based clinics (RBCs), which offer a limited range of health services in places like Target and Wal-Mart. Such clinics are commonly staffed by nurse practitioners (NPs). Organized medicine has argued that RBCs do not provide adequate continuity of care, and that the NPs need physician supervision. This article, by physician Ranit Mishori, actually includes quotes from an NP who defends the model of care. However, her role in the piece seems more due to the fact that she is the manager of operations for the Washington, DC area MinuteClinics; her status as an NP is only revealed in a quote from her well into the piece. For its outside "expert" advice on the NP care at the clinics, the piece relies solely on comment from three named physicians, and physician groups. The piece consults no outside NP experts or nursing groups, and apart from a few of the MinuteClinic NP's comments, tends to suggest that the real issue is what the physicians who provide all important primary care make of this apparent threat to their practices. In fact, studies show that NPs themselves provide comprehensive primary care that is at least as good as that provided by physicians--the choice is not solely between RBCs and physicians. Thus, although this piece is clearly more balanced than some, it undervalues NP care.
The piece is headlined: "Is 'Quick' Enough? Store Clinics Tap a Public Need, but Many Doctors Call the Care Inferior." The first paragraph: "Some of the newest players in health care are rubbing doctors the wrong way." This establishes the issue nicely--what do physicians, the only truly expert health professionals, make of these clinics? Many physicians are concerned at the quality and continuity of care provided, especially for children, but will the physicians be undermined by the clinics or learn to adapt to them, perhaps streamlining their own practices to compete better?
The piece explains the opposition to the clinics by the American Medical Association and the American Academy of Pediatrics (AAP), and refers to the response from the American Academy of Family Physicians (AAFP). It also quotes three physicians: the AAFP president, a past director of the AAP, and a DC area pediatrician. The latter two are vehemently opposed to the use of RBCs for children, and all stress that patients should go to "their regular doctor" for "chronic illnesses or complex problems." Inexplicably, there is no responsive comment from any nurse practitioner association (would an article mainly about physician care consult only three NP associations?).
The upshot of the physician comments seems to be that only pediatricians can offer comprehensive, quality primary care to those under 18. The DC area physician alleges that in two cases she knows of, a local MinuteClinic failed to provide proper antibiotic prescriptions and good follow-up.
On the other side, the piece consults executives of MinuteClinic (which is now owned by CVS). Its "chief medical officer" cites its "long track record" of convenient quality care. He also expresses concern about the two cited cases, noting that the clinics adhere to AAFP and AAP protocols on antibiotic prescriptions, and more broadly that MinuteClinic data show extremely low error rates for relevant conditions.
The piece also gives a surprising amount of space to comments from Anne Pohnert, "MinuteClinic's manager of operations for the Washington area." About two thirds of the way into the piece, 14 paragraphs after she is introduced, we learn from a helpful Pohnert quote that she is in fact an NP:
We are all experienced nurse practitioners who typically have years of nursing experience in various fields as well as training and experience in family practice. We don't lose that knowledge when we come to MinuteClinic. We bring it with us and use it every day to make good clinical decisions that are appropriate for patient care in our setting.
This is a good quote. Of course, it does not convey that NPs typically have masters degrees in nursing, that outside of RBCs they provide just the kind of comprehensive primary care the piece suggests is needed for kids and serious conditions, and that research has found this care to be at least as good as that provided by physicians. Pohnert also explains that MinuteClinic NPs and physician's assistants do take "medical histories" and are careful to "refer out" when needed.
Unfortunately, some of Pohnert's reported comments seem to reinforce the notion that that the only person to use for care for "chronic illnesses or complex problems" is your "regular doctor." She is quoted as saying that "[w]e have a certain number of diagnoses and only treat minor common family illnesses . . . that we have guidelines for." Of course patients with problems beyond the RBC scope of care should get care elsewhere, but this makes the NPs sound like people who can only follow simple protocols. In fact, NPs are expert at diagnosing and managing serious chronic conditions. And the comment seems to undervalue what NPs do even at the RBCs, which offer health screenings and important vaccinations. Pohnert does note that the RBCs can serve as an "early warning system" for patients who may visit for a "some minor ailment" but find that they have something more serious. She also notes that RBCs provide care for many who otherwise might not get any, including the uninsured, travelers, and those who have no "regular physicians."
Pohnert also argues strenuously for a "can't we all just get along?" approach to relations between RBCs and primary care physicians, suggesting that there are plenty of patients for everyone and the future will involve health collaboration between RBCs and "traditional medicine." The piece actually closes with quotes from Pohnert to the effect that "[w]e'll make it work for everybody." It is left to the AAFP president to acknowledge that his members are concerned about "the economics of their business." Of course, it is common even for outside NP experts to suggest that there is plenty of primary care business to go around. However, we can still think of economic reasons that some physicians might wish to discourage patients from seeking NP care in physician-free settings.
On the whole, the piece is certainly more balanced than many that examine physician objections to RBCs. And we give Mishori credit for including so many quotes from Pohnert, even if her status as an NP (rather than just a MinuteClinic manager) is underplayed. But the piece fails to give an adequate account of NP training or expertise, fails to consult outside NP experts to balance the outside physicians quoted, suggests that physician views of primary care are the ones that really matter, and promotes the incorrect idea that only physicians provide comprehensive primary care. And the piece, like many others, undervalues what the RBCs do: vaccinations and screenings, which have saved millions of lives, are not "minor."
See the article "Is 'Quick' Enough?: Store Clinics Tap a Public Need, but Many Doctors Call the Care Inferior" from the January 16, 2007 edition of the Washington Post.
Also see a good article by Tracy Klein, RN, MS on NP autonomy: "Working in a Retail Clinic: What Nurse Practitioners Need to Ask" on Medscape from September 20, 2006.