Fast, Cheap & Out of Control

November 14, 2005 -- This morning, NBC's popular "Today" show included a short, troubling segment with reporter Janice Lieberman about the recent growth in nurse practitioner-staffed "quick clinics" at U.S. supermarkets and drug stores. The piece did stress that the clinics offer convenience and affordability for basic care that consumers appreciate. Lieberman even got her flu shot on camera. But the item also degraded the "cheap" NP care available at the "quickie" clinics, ignored NPs' vital role in more comprehensive primary care, and suggested that autonomous NP care presents safety risks, relying on a baseless, paternalistic quote from AMA president "Dr. Edward Hill." The piece did not allow NPs to defend their care from these sloppy attacks. Instead, the only audible NP speech it offered its audience consisted of an NP, identified only as "Kathy," saying "ready" to indicate that she was ready to give Lieberman her flu shot.

See the film clip (if you have a PC) or read the transcript.

The piece runs about 3 1/2 minutes and has the onscreen subtitle: "Walk-in Health Care: Are Quick Clinics Worth It?" Host Katie Couric introduces the segment. She notes that the "quickie" clinics are responding to patients' weariness with long waits to see their "doctor[s]," but asks, "are you putting your health at risk?" Lieberman begins her piece from a CVS store "where you can fill your basket with diapers, mouthwash and shampoo, and get a quickie diagnosis on the cheap." The piece runs a clip from "Curb Your Enthusiasm" in which Larry David starts to lose it after having to wait at a physician's office and dealing with the immovable office bureaucrats, who may or may not be nurses. Lieberman comes back and talks to shoppers who avoid this "hassle and expense" by getting care at the supermarket. Lieberman notes that companies like MinuteClinic are increasingly putting "medical kiosks" in such stores at which patients simply sign in, start shopping, then soon get paged for care at clinics whose "goal is to examine, prescribe and medicate patients, sending them on their way before their frozen food melts."

However, Lieberman explains, "critics are concerned that MinuteClinics are staffed by nurse practitioners who are licensed to treat patients and prescribe medications, but have far less training than doctors." Suddenly, though we have been watching visuals of the store environments with significant background noise, the piece moves to an authoritative talking head interview clip with "Dr. Edward Hill," the president of the American Medical Association. (Silence! An authoritative health care expert!) Hill explains that "[o]ur only concern is that we don't confuse convenience and affordability--even affordability with quality. And...there's a concern about supervision of these non-physician providers." Then "Dr. James Woodburn," apparently the MinuteClinic's medical director, appears to assure viewers that the clinics are "not a replacement for the primary care relationship." A moment later, a patient compares NP quick clinic care to that of a "regular doctor": "I go to a regular doctor when it's a mystery, I don't know what's going on." Lieberman ends the piece by getting her flu shot on camera, noting in passing--no big deal--that MinuteClinic has given 60,000 flu shots. She turns to the clinic NP and says: "Ready, Kathy?" Kathy responds: "Ready." Although the piece has shown NPs giving care throughout, and at times we can tell that they are speaking to patients, Kathy's word is the only one an NP delivers to the television audience in the entire piece.

So what's wrong with that? Most obviously, though the segment talks to several patients and physicians, it fails to get any comment from the NPs whose care is the subject of the piece--a mark of disrespect that would be amazing, if we weren't talking about nurses. So there is essentially no rebuttal to the scary suggestions that patients may be "putting [their] health at risk," that NPs have "far less training" than physicians, that NPs provide poor quality care and need physician supervision, and that NPs are unable to diagnose, and so can only help when patients already know what's wrong with them.

In fact, as the piece fails to note, NPs typically have six years of college-level training, a four-year bachelors degree in nursing and a two-year master's degree in nursing. And even if NPs did have somewhat less formal training than physicians, that would not mean their care was inadequate. On the contrary, extensive research has demonstrated that NP care is at least as good as that of physicians. The piece provides no evidence, even anecdotal, of any specific problems with the quality of NP care, at quick clinics or elsewhere. None.

In addition, "Today"'s U.S. viewers might never know that the nation's 110,000 NPs actually play a vital role in comprehensive primary care, especially in underserved communities, nor that their diagnostic skills are excellent. As skilled professionals, quick clinic NPs are well qualified to refer patients to other primary care providers when that is indicated. NPs do not need physician "supervision," though some legislation may nominally require that. Because physicians compete with NPs, comments like those of Dr. Hill generally reflect economic self-interest, bias, and/or genuine (if uninformed) concern about patient safety. The "Today" producers should have realized that NPs deserved a chance to defend their work. The inclusion of only physician comment suggests that only physicians are qualified to comment on nursing care--an absurd misconception.

Even the piece's language degrades NP care. Patients reportedly get a "quickie diagnosis on the cheap" in between diapers and toothpaste, the clinic NPs work in "kiosks" (do they sell magazines too?), and they seem to have only first names, as opposed to the esteemed physicians who are addressed as "Dr. ____." We realize that working in a quick clinic means you will have to face comparisons of your care to the surrounding consumer products. But the piece fails to provide balance as to NPs' skill or the importance of their care. At worst, the segment's "cheap quickie" language has overtones of illicit sex. At best, it suggests that NP care is fast, cheap and out of control.

The piece also largely ignores the huge public health benefits of the preventative care at which NPs excel. The quick clinic NPs provide affordable, convenient health screenings and vaccinations. We hear about the 60,000 flu shots, but there is no suggestion that many if not most of the recipients may otherwise not have gotten a flu shot at all, nor any hint that influenza continues to kill tens of thousands in the U.S. alone each year. Vaccinations and screenings have saved millions of lives. And if more people had access to them--such as the 1 in 6 Americans who now lack health insurance--they could save millions more. The quick clinics are not meant to provide all primary care, but they may help many patients get vital care they would not otherwise get at all. Such NP-run clinics may be a promising new basic care model in an often hostile and inaccessible health care system.

UPDATE -- December 4, 2005

"Today" quick clinic campaign on fire

December 4, 2005 -- Over the past two weeks, 3500 nursing supporters have sent letters to NBC's "Today" Show. They have objected to the November 14 segment in which nurse practitioner (NP) care at "quick clinics" was portrayed as fast, cheap and out of control, and in which AMA President Edward Hill was allowed to deliver unfounded criticism of the quality of NP care, with no response from an NP. Letters came from every part of the United States and abroad, from nurses in rural clinics, major teaching hospitals, and the military, and from patients and physicians. An astonishing 42% of the letters were original. Because of this outpouring of concern, the Center has been able to establish a contact with a "Today" Show producer. He has promised to work with us on presenting accurate information about nurses through "Today" and possibly other venues. We understand that a statement about the Nov. 14 segment from the "Today" Show is forthcoming, but it was not available in time for this news alert. We plan to set up a working group of nursing organizations to pitch story ideas about nurses to the show on a regular basis. To learn more about being part of this working group, please contact me at ssummers@nursingadvocacy.org. If you have an idea for the show, please send a one paragraph summary to storyidea@nursingadvocacy.org. AMA President Hill has not responded to the 3500 letters the AMA has received, and he has failed to return our many calls asking for a dialog. Please send our new letter to the AMA asking it to base policy positions about nurses on research, rather than bias or economic self-interest. Thank you.

December 14, 2005 -- UPDATE -- see our update on this campaign below.

Take Action! Please click here to send our new instant letter to the AMA. Thank you!

Transcript of the "Today" Show segment in question:

Profile: Growing trend of quickie medical clinics in supermarkets and drugstores

November 14, 2005
NBC News: Today

KATIE COURIC, co-host:

And this morning on TODAY'S CONSUMER, quickie medical clinics. If you're tired of waiting eons to see your doctor, these medical centers in your supermarket or drugstore could be just the cure. But are you putting your health at risk in the process? TODAY's consumer correspondent Janice Lieberman is at a drugstore in Andover, Minnesota, this morning, where you can buy more than just toothpaste.

Right, Janice?

Good morning.

JANICE LIEBERMAN reporting:

Exactly. I'm at a CVS store where you can fill your basket with diapers, mouthwash and shampoo, and get a quickie diagnosis on the cheap. Clinics like these are already rolling around--around the country at Targets and Wal-Marts and other clinics, leaving new meaning to the term "shop until you drop."

You rush to the doctor's office. You have the appointment, you do the sign in, and after all of the hustle, it's a wait.

(Beginning of clip from "Curb Your Enthusiasm")

Unidentified Woman #1: There's no need to get upset. We have a policy in this office that you are seen as you sign in.

Mr. LARRY DAVID: What is it--what is it...

(End of clip)

LIEBERMAN: Larry David made fun on of it on "Curb Your Enthusiasm" because it's something we've all experienced.

(Beginning of clip from "Curb Your Enthusiasm")

Woman #1: That is the policy of this office.

Mr. DAVID: You understand this policy?

Woman #1: Please don't talk to her. She's busy.

(End of clip)

LIEBERMAN: There's got to be an easier way. Lori Lauren says she doesn't have time for the wait or the hassle and expense of seeing a doctor. So instead of the waiting room, she comes here, her local supermarket.

Ms. LORI LAUREN: It saves a lot of time if I can go one place and get the few things I need to make dinner and take care of the strep throat.

LIEBERMAN: The checkout checkup is part of a growing trend spreading across America, run by companies like Minute Clinic, who put medical kiosks in drugstores, office parks and even discount stores like Target. In this store, patients simply sign in and take a beeper while they shop, but the wait is usually less than 15 minutes. With rapid tests for everything from strep throat to the flu, the goal is to examine, prescribe and medicate patients, sending them on their way before their frozen food melts.

Unidentified Woman #2: I probably saved about an hour just in--in--and I was also able to get my shopping done as well.

LIEBERMAN: But critics are concerned that Minute Clinics are staffed by nurse practitioners who are licensed to treat patients and prescribe medications but have far less training than doctors.

Dr. EDWARD HILL (President American Medical Association): Our only concern is that we don't confuse convenience and affordability--even affordability with quality. And a conc--there's a concern about supervision of these nonphysician providers.

Dr. JAMES WOODBURN (Minute Clinic Medical Director): Minute Clinic is not a replacement for the primary care relationship. We value that as well.

LIEBERMAN: While convenience is a big selling point, Minute Clinic says another benefit is savings, posting prices just like the supermarket it's housed in.

Unidentified Woman #3: When I look at the care that I want to get from a nurse practitioner compared to a regular doctor, I go to a regular doctor when it's a mystery, I don't know what's going on.

LIEBERMAN: Well, we're at Minute Clinic right now, and they've already given out 60,000 flu shots, Katie. I'm a little behind the time. So I'm getting one. Don't look, Katie. I know you don't like to look at these.

Ready, Kathy?

KATHY: Ready.

LIEBERMAN: Ahh! No, it's not bad. At $30 a pop, it's not bad. If you had a prescription to fill you could do that right here. So it's, you know, one-stop shopping.

COURIC: Yeah, absolutely. My parents are going to tell me to go there because they've been bugging me to get a flu shot. All right, Janice. Thanks so much.

LIEBERMAN: OK.

COURIC: And up next, spanning the world with Matt. We're going to take a look back at this year's incredible wor--WHERE IN THE WORLD adventures. But first these messages.

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