On the fourth day, Betty seemed lethargic, and she refused to move from the couch or eat the Cheetos she loved. Stacey Wattenbarger thought she and her husband, Jeremy, should take their seven-year-old daughter to the emergency room. She had that intuition every mother knows all too well: Something was wrong with her child. Jeremy, a forensic investigator who was working from home, was not so sure about the hospital. He had always been close to his younger daughter—his “little buddy,” as he called her—and he was usually the parent who took Betty, who had been diagnosed with autism at 18 months, to the Wattenbargers’ pediatrician, Jeremy Baker.
Baker, however, was not seeing acute, walk-in appointments that Wednesday afternoon. His staff recommended the nearest pediatric urgent care, in Denton, Texas. Although the clinic was almost 30 minutes away, Jeremy agreed that, because of Betty’s autism, a pediatric facility was best.
Stacey, however, felt strongly that Betty needed to go to Baylor Scott & White Emergency Hospital, less than a mile from the family’s home in Aubrey, Texas. In fact, as Betty lay in the back seat of Jeremy’s pickup truck, the couple argued about where they were heading. Baker’s staff had told Jeremy that a pediatric urgent care would have the expertise Betty needed. The family had always listened to their pediatrician when Betty had recurrent ear infections and allergies, and Jeremy thought they should listen to his staff now. In the end, Jeremy overruled Stacey.
In the waiting room at Pediatric Urgent Care Denton, Stacey, still uncertain whether they’d made the right choice, took a photo on her cell phone and sent it to her mother, Carolyn. In the picture, Betty, a wisp of a girl with short blonde hair and blue eyes, looks pale, expressionless, exhausted. Her lips are blue. After admitting Betty, a practical nurse collected her vital signs. Betty’s temperature was high, about 102.5 degrees Fahrenheit. Her heart rate was 170 beats per minute. The nurse struggled to get Betty’s oxygen level to register on the machine. Finally, the girl’s toe registered 94 percent, but the reading fluctuated as low as 88 percent. Anything below 95 percent is considered abnormal. Stacey wondered about the blueness of Betty’s lips. “Are they usually that color?” the nurse asked. Stacey said that they were not. Seemingly unconcerned, the nurse shrugged.
In a treatment room, a woman with a stethoscope around her neck swabbed Betty’s nose for influenza and gave her oral ibuprofen for her fever. Ordinarily, Betty refused to swallow medicine; today, she took it without a fight. The woman asked some questions but did not ask about Betty’s medications, allergies, past medical history, or exposure to illness. She did not introduce herself. After looking at Betty’s ears and throat and examining her heart and lungs, she left the room.
A few minutes later, she informed the Wattenbargers that Betty had tested positive for influenza A, the most severe version of the seasonal flu. Stacey asked about Betty’s rapid breathing and, for a second time, about her blue lips. The woman with the stethoscope blamed it all on Betty’s high fever. After reassuring Jeremy and Stacey that Betty’s lungs were clear, she said their daughter “should be fine.”
Soon, the Wattenbargers were told they could leave. As they headed toward the door, Betty stopped walking and turned toward Jeremy. She was asking to be picked up, something she asked of her father often. He had come to intuit such requests. His own rough childhood—there was no running water or electricity on the Midwestern farms he grew up on—had made him especially attentive to his daughters, and he had tried hard to better Betty’s and her older sister Annabelle’s lives. He danced and sang along with them to the television series Yo Gabba Gabba!, and he had even painted Betty’s room the same chartreuse green as her favorite monster on the show. Knowing his younger daughter well, Jeremy bent down, picked her up, and carried her out to the parking lot.
As they left, Stacey felt reassured. Because nobody at the urgent care had seemed troubled by her daughter’s condition, she even felt a little stupid for worrying so much. That evening, Betty took small sips of Pedialyte, sat at the dinner table, and ate a little. Stacey noticed that Betty’s cough had worsened since earlier in the day, so she gave her some cough syrup before bed. When sick, Betty tended to prefer her father. But in the middle of the night, she got into her parents’ bed and snuggled as close as she could to her mother, who relished the chance to hold her. Stacey often wondered whether Betty favored Jeremy because he hadn’t mourned the autism diagnosis to the extent that Stacey had. Perhaps, Stacey thought, Betty had turned toward her father because she felt slighted by her mother’s pain. As Stacey lay in bed with Betty next to her, she felt not only that Betty was improving but that a new chapter in their relationship might lie ahead.
The next morning, though, Betty was not better. In the shower, she fell over. Wanting to make his daughter comfortable, Jeremy brought her mattress into the living room and put it next to the fireplace. Moments later, he saw a dark substance coming out of Betty’s mouth. He yelled for Stacey, who ran in from a small room just off the kitchen. When she saw the dark liquid, her first thought was that it was the grape cough syrup she’d given Betty earlier that morning. But Jeremy knew it was blood. In a matter of seconds, he carried Betty outside and placed her in the back seat of his truck. With his horn blaring, he drove to the end of the street, ran a stop sign and two stoplights, and in under two minutes arrived at the Baylor Scott & White Emergency Hospital, where the emergency room staff sprang into action.
After changing out of her pajamas, Stacey arrived a few minutes later. Jeremy’s truck was parked at the emergency room entrance. The doors were wide open, the engine still running. Stacey prayed Betty was alive. But she wasn’t.
Over the days and weeks that followed, certain moments lingered in Jeremy’s and Stacey’s minds: the sound of the flat-line, which Stacey could hear from the trauma bay next door; the emergency room physician asking Jeremy if he wanted to continue CPR; Stacey screaming at Jeremy that this was his fault: “I will never forgive you for this!”; the silent drive to the elementary school to tell Annabelle; Annabelle thinking that perhaps her hamster had died when she was ushered into a conference room where, along with her parents, she saw her principal, a school counselor, two teachers, and her mother’s best friend; Annabelle sobbing uncontrollably when Stacey told her, “Betty is in heaven.”
Why had Betty died? Amid the unceasing pain of mourning, the question looped in Stacey’s and Jeremy’s heads. Stacey, who had a GED and had begun working for herself as a graphic designer, reviewed old medical records. Jeremy, who held double master’s degrees, called lawyers, wondering how an urgent care clinic could release a child who, 16 hours later, would die. Few called Jeremy back. Those who did told him children die of influenza “all the time.” Jeremy refused to accept the explanation.
Stacey kept digging, too. In March 2019, a month after Betty’s death, Stacey found her daughter’s information on the Tarrant County Medical Examiner website. Along with her name and date of birth, Betty’s cause of death: sepsis complicating pneumonia with influenza A. Sepsis, Stacey learned after some quick Googling, is blood poisoning.
A few days later, seeking further clarity, the Wattenbargers spoke with Tasha Greenberg, a deputy medical examiner in Tarrant County. Greenberg explained how the influenza had made Betty susceptible to a bacterial infection. Because Betty’s pneumonia was so severe, it quickly spread to her bloodstream and became fatal. When Stacey asked about Betty’s overlooked symptoms, Greenberg acknowledged that Betty’s low oxygen reading was “concerning”: “To me, that’s more indicative of the fact that she had pneumonia.” The autopsy had found nearly half a cup of thick fluid and blood in Betty’s lungs. Jeremy found it difficult to believe that Betty’s lungs would have sounded normal at the urgent care; Greenberg acknowledged that she had “difficulty” with that part.
In fact, when Betty died, some of the cells in her left lung were already necrotic, indicating that her lungs had been infected a few days prior to her death. “It’s not like it just developed after she had been to the urgent care,” Greenberg explained. The infection was severe. In other words, although Greenberg did not say so, it was highly likely that when Betty was seen at the urgent care, she already had pneumonia. That meant that she had been misdiagnosed, and should never have been sent home.
Stacey requested a copy of Greenberg’s medical record file, which included the urgent care medical records, but Greenberg declined, explaining that the medical examiner’s office was not authorized to release them.
Shortly after the conversation, Pediatric Urgent Care Denton sent Jeremy a bill for services provided. The cost of Betty’s care was only partly covered by insurance. The Wattenbargers owed $131.17 to the clinic where their dead child had been misdiagnosed.
Once Jeremy moved past his outrage, he noticed something unusual on the bill. The medical professional listed as treating Betty was Madeline Broemsen, P.N.P.-P.C. What’s that? Jeremy thought. He knew that physicians have a designation of M.D. (doctor of medicine) or D.O. (doctor of osteopathy). But a P.N.P.-P.C. is something else entirely. Jeremy looked into it. More than one month after Betty died, the Wattenbargers learned that she had not been evaluated by a physician.
The woman with the stethoscope in the office? That was Madeline Broemsen, a nurse practitioner.
I’ve been a practicing pediatrician for 20 years, and for a decade I have been alarmed by the dramatic rise of urgent care facilities. In theory, such clinics fill a need: They accept unscheduled, walk-in patients; they diagnose and treat nonlife-threatening illnesses and injuries; and they provide access to on-site X-ray and laboratory services. For patients, the convenience they offer is hard to beat. After the 2010 Affordable Care Act gave patients more freedom to choose where they receive care, urgent care facilities began popping up all over the place. Indeed, there are now more than 10,400 urgent care clinics nationwide. As of five years ago, the Urgent Care Association of America estimated that there were 575 in Texas alone. Between 2010 and 2014, the industry grew by 20 percent; it is one of the fastest-growing segments of health care in the United States. In 2021, annual urgent care revenue reached approximately $39 billion. (For comparison, emergency department care for the entire U.S. population cost a total of $76.3 billion in 2017.)
Unfortunately, the quality of care at these facilities depends in large part on the quality of the staff’s education. Urgent care clinics often look as if they are staffed by physicians, but many are staffed exclusively by nurse practitioners, who can be—and often are—mistaken to be doctors. According to the Urgent Care Association of America’s 2014 survey, only around 20 percent of urgent care clinics “use physicians only.” Put differently, as many as 80 percent rely on nurse practitioners or physician assistants to oversee care, under what can only be assumed are varying levels of oversight by physicians. (The survey did not evaluate supervision.) Although comprehensive studies on misdiagnoses and wrongful deaths at urgent care clinics are sparse—not least because the facilities haven’t been around that long—what we do know is that nurse practitioners have as little as 3 percent of the clinical training hours undergone by physicians.
One does not have to look very far to understand the reason for these facilities’ reliance on nurse practitioners and physician assistants: Doctors are far more expensive to employ. An emergency physician earns an annual salary of almost $300,000 on average, whereas an N.P. or P.A. working in the emergency department commands less than half that amount, around $130,000 per year. Rather than passing on the savings, however, urgent care facilities still charge patients as if a physician were present. The combination of cheap labor, high profits, and high demand helps explain the boom in urgent care centers across the United States, and particularly who owns them. Thirty-nine percent are owned by private concerns, either private-equity firms or other profit-seeking corporations. Thirty-one percent are owned by hospital chains or joint ventures with hospitals. Just 14 percent are owned by physician groups. One study from the American Investment Council showed that, in 2020 alone, private-equity companies claimed at least partial ownership of more than 250 urgent care facilities in the United States, with an estimated value of more than $15 billion.
More empirical examinations of the urgent care sector are needed. But they won’t be easily forthcoming. Privately owned facilities, which make up 70 percent of the urgent care market, are under no obligation to turn over information for research purposes. And secrecy and self-censorship abound. Indeed, physicians employed at large health organizations composed in part of urgent care facilities have been dismissed merely for discussing the difference between nurse practitioners and physicians. In one high-profile case, Dr. Steve Maron, an Arizona pediatrician, was fired from United Community Health Center’s Green Valley clinic after writing an opinion piece headlined “ARE NPS SAME AS MDS?” His employers terminated him for violating the organization’s “principle of mutual respect.”
The question of whether N.P.s ought to be allowed to practice without supervision or run their own clinics is undoubtedly a contentious debate within medicine, and it can seem like the bickering between physician associations and nurse practitioner or physician assistant associations boils down to nothing more than a turf war. But it’s about much more than that. Health care, whether we like it or not, has become big business. On all sides, the debate is more about money, power, and clout than ever before. At the end of the day, there are not enough physicians to go around—one reason that a viral pandemic has brought our health care system to the brink of collapse.
Nursing organizations—as well as the right-leaning American Enterprise Institute—have been quick to note that N.P.s could fill the growing shortage of primary care faster than physicians, because it takes them six years to complete their education and training, including undergraduate and graduate degrees, compared to the 11 to 12 years doctors need. But while the nursing organizations make a good point, there are some unanswered questions. First, the differences in education and training are rather stark. Physicians accumulate at least 15,000 hours of practice under supervision by a fully trained physician before being allowed to work independently. Today, a nurse practitioner can work independently after completing merely 500 hours. In addition, nurse practitioners may be accepted into graduate school without having any prior nursing experience; some may complete their education entirely online. Some physician organizations, consequently, are concerned that substituting nurse practitioners and physician assistants in place of physicians might put patients at risk. After all, physicians make plenty of mistakes despite their extensive training. Are N.P.s and P.A.s likely to make fewer errors with less education? Common sense alone suggests that diagnostic accuracy improves with more training.
Yet there is, unfortunately, little research to bolster the claims of either camp. One recent study published by the American Association of Nurse Practitioners’ trade journal found that, when collaborating with physicians, the accuracy of diagnoses by N.P.s and P.A.s was comparable to that of doctors. However, the only statistically reproducible finding to come out of the study was buried in the fine print: N.P.s and P.A.s made “significantly more inaccurate assessments” in children with abdominal pain than physicians did. A similar study evaluating adults with abdominal pain in emergency settings revealed that diagnostic accuracy was highest when nurse practitioners or physician assistants collaborated with physicians.
Sophia Thomas, a nurse practitioner and previous president of the American Association of Nurse Practitioners, has told other news outlets that nurse practitioners are well equipped to provide urgent care to patients in nurse practitioner–owned practices. When asked if she thought it was acceptable for an N.P. to work alone in an urgent care with no physician available, Thomas said, “The question of quality and safety around N.P. care has been asked and answered by more than 50 years of rigorous evaluation.” The rigorous research Thomas was referring to, however, assessed the quality of care by N.P.s and P.A.s while working under the direct supervision of physicians in phone triage, primary care, or specialty clinic settings; it did not consider whether it’s safe to replace physicians with independent nurse practitioners in emergency settings. In fact, no studies have examined that question.
My view, obviously informed by my own training, is that while N.P.s, P.A.s, and nurses are integral members of the health care team, their role should be circumscribed: In primary care, emergency, and specialty settings, they should work under direct supervision. The Journal of Nursing Regulation, the official publication of the National Council of State Boards of Nursing, agrees that, under current conditions, N.P.s should not perform unsupervised care in emergency settings, regardless of state law or hospital regulations. Indeed, many nurse practitioners and physician assistants prefer working collaboratively in teams with physicians. Yet, if studies repeatedly demonstrate that collaboration is safest for patients—and many N.P.s and P.A.s prefer it—why are nurse practitioner and physician assistant organizations pushing so hard for independence? It comes back to the money. The organizations advocating for more employment options and higher status for their members are ultimately in alignment with the corporations that own urgent care clinics, which want to employ staff who are cheaper.
Meanwhile, regulation of the urgent care industry is severely limited. A report released in March 2021 by Community Catalyst, a health care advocacy organization, and the National Health Law Program, a civil rights advocacy group, revealed that just a handful of states—Arizona, Nebraska, Michigan, Connecticut, and New Hampshire—require facility licenses specifically for urgent care clinics. Without licensing requirements, the vast majority of urgent care facilities evade the scrutiny of even state health departments.
What’s more, no federal legislation exists to regulate the industry, and no one in Congress is taking up the cause of creating any. In Donald Trump’s misguided attempt to privatize Medicare, he signed an executive order in October 2019 that called for eliminating supervision requirements of N.P.s and P.A.s at facilities that see Medicare patients. It also encouraged reimbursing physicians, N.P.s, and P.A.s equally regardless of clinical training. The order incentivized corporations within the Medicare system to hire health care workers with less training, pay them lower salaries, and charge patients more, resulting in larger profit margins for the owners. Increasingly, those owners are private-equity firms, which seldom have to disclose whom they’re lobbying. As one monthslong New York Times investigation showed, it can be difficult to track even basic information about which K Street lobbyist is speaking with which politician on behalf of which health care interest.
It’s as infuriating as it is frightening. After the unnecessary death, in 2015, of 19-year-old Alexus Ochoa-Dockins, who was cared for by a family nurse practitioner working solo, I wrote a book about the risk patients face at urgent cares and emergency departments without on-site physicians. Ochoa-Dockins was an honor student and a standout basketball athlete; she died after spending 11 hours at the Mercy Hospital emergency department in El Reno, Oklahoma. The unsupervised nurse practitioner misdiagnosed her with a drug overdose; in reality, she had bilateral pulmonary emboli (or blood clots in the blood vessels to both lungs).
Since my book came out, I have heard from an ever-greater number of parents whose children died after being treated in unlicensed urgent care facilities. Many cases are still winding their way through the courts. In 2017, Kassie McAtee lost her one-year-old son, Kyler George, after taking him to an urgent care clinic at a CoxHealth hospital in Branson, Missouri. A P.A. misdiagnosed Kyler with an ear infection; he died of heart failure three hours after being discharged home. In 2016, four-year-old Olivia Steinborn was discharged from a freestanding facility run by Excel ER in Dallas, Texas, after being evaluated by a resident physician; five hours later, she died of meningitis. Les Weisbrod, the lawyer representing the Steinborn family, said the clinic “was too cheap, and looking too much in the way of profits, to pay for a real physician who had finished training.” (Residents, who have not yet completed their training, are not allowed to treat patients without supervision.)
The time is well past for federal regulations to mandate that all emergency departments and urgent cares have fully trained physicians on-site at all times. Furthermore, if state health departments required licensing of urgent care clinics, the clinics would fall under stricter regulations, and would have to, for example, clearly identify whether or not a physician is on the premises. Stricter regulations would lead to better diagnoses and, frankly, fewer deaths.
As the Wattenbargers found out, there is much that needs to be done.
After learning that Betty was not treated by a physician, Jeremy filed a complaint with the consumer protection division of the Office of the Attorney General of Texas. He argued that the urgent care violated the Texas Deceptive Trade Practices Act by not disclosing the qualifications of its clinicians, since the law prohibits corporations from misrepresenting the standard and quality of services offered. Other than acknowledging Jeremy’s complaint, the attorney general’s office did not respond.
The Wattenbargers also filed a lawsuit against the Denton urgent care practice. In deposition testimony, the couple learned that Broemsen, who declined to speak to me for this story, owns a 59 percent majority stake in Just 4 Kids Urgent Care, as the practice is now called. Michael Cowan, the clinic’s medical director at the time of Betty’s death, retains 20 percent ownership, though at the time of her visit he owned 51 percent. (Cowan also declined to speak to me.) A “silent” investor, Frank R. Scheer—Broemsen’s father and a board member of the local Ciera Bank—owns 21 percent. A doctor friend of Scheer’s, Dale Swanholm, currently serves as the facility’s medical director. Swanholm is a geriatrician. In other words: At Just 4 Kids Urgent Care, a doctor specializing in care of older adults supervises a nurse practitioner who sees only children.
In the months after Betty’s death, Jeremy became almost rabid in his search for accountability. When he filed a complaint against Broemsen with the Texas Medical Board, he learned that the board only enforces “those requirements governing the practice of medicine.” Because Broemsen is a nurse, the complaint about his daughter’s misdiagnosis was not “within its jurisdiction.” The complaint was referred to the nursing board, which ignored it.
Finally, the Wattenbargers filed a medical malpractice lawsuit, and hired Andrew Lawson, an emergency physician, to review Betty’s records. From the records, Lawson concluded that Broemsen had made countless errors. Only some vital signs were checked. No respiratory rate was documented, yet Broemsen noted Betty’s respiratory rate to be “normal.” The nurse described Betty’s heart rate of 170 beats per minute as “normal,” when a heart rate above 130 beats per minute should raise concern for sepsis.
These signs of impending sepsis, Lawson wrote in his review, meant that Betty “should not have been discharged home.” He argued that Broemsen, Cowan, and all the clinical support staff breached the acceptable standard by not rechecking vital signs, including checking a respiratory rate, and by not performing additional blood testing that afternoon.
Jeremy next contacted Pat Fallon, a state senator in Texas at the time. Patricia Vojack, a health care policy expert and special counsel to Fallon, lent a helping hand. With Vojack’s assistance, Jeremy’s third complaint to the Texas Board of Nursing yielded results: The board determined that Broemsen had rendered care that fell below the “minimum acceptable nursing standard.”
In December 2019, Broemsen was sanctioned with three years’ probation and completed four “remedial” courses in nursing ethics, nursing documentation, sharpening critical thinking skills, and professional accountability. The nursing board did not address the possibility that Broemsen’s mistakes may have killed Betty. Broemsen was not required to learn about treatment of sepsis or bacterial pneumonia in children, knowledge that might save the life of another child. In fact, the nursing board faulted the Wattenbargers for not pressing Broemsen harder: “Ms. Broemsen’s statement indicates she was not questioned or made aware of any concern regarding your daughter’s lips.” Apparently, the Texas Board of Nursing expects parents to play doctor when nurses are unable.
I wish I could say that this statewide lack of accountability was unique in cases involving N.P.s and deaths of patients. What I can say instead is that nearly three years after Betty’s death, her family remains shattered. Stacey struggles the most. “A part of me died that day,” she told me. For a year, she could not enter her own living room. She wanted to move, but Jeremy clung to the familiarity of the home where they had lived with their daughter.
Trying to erase the memory of Betty’s tortured last moments, the Wattenbargers made changes to their house. They pulled up the living room floor where Betty died, keeping just one piece of floorboard. Wanting the house to look different out front, they put in raised flowerbeds. Next, they changed out the kitchen flooring and the countertop. But they couldn’t part with the granite slab where Betty wiped the cheesy residue from Cheetos on her fingers, leaving oily smudges underneath. When I visited, a four-foot-by-four-foot chunk of stone still sat against the wall in the garage.
Betty’s room, painted chartreuse, remained unchanged. Stacey started spending most of her time in a windowless room that used to be Betty’s old learning center, where she worked on her flourishing Etsy business, so Jeremy moved into Betty’s room and gave Stacey his office space, which had more light. When Jeremy wanted to try for another child, Stacey felt conflicted; she had had a tubal ligation following the birth of her second child. Nevertheless, knowing how much it mattered to her husband, Stacey had a reversal operation. They were not able to conceive.
In many ways, the Wattenbargers remained stuck in 2019. Stacey had panic attacks when driving past places that reminded her of Betty. Annabelle loves to bake, but Stacey no longer wanted to spend time in the kitchen. Sometimes, working on her Etsy business staved off the grief. With every fulfilled order, she tried to lock away the pain of losing her child.
Wanting to hold Broemsen and Cowan accountable, Jeremy sent dozens of letters to the Texas Board of Nursing and Texas Medical Board. With every complaint that went unanswered, with every politician at the state and national level who refused to legislate the issue, he grew angrier.
Meanwhile, Broemsen continues to operate Just 4 Kids Urgent Care. The lawsuit against her, Cowan, and the urgent care practice for medical negligence is still pending. A trial is scheduled for April, but the case, as do almost all medical cases in Texas, will first go to mediation and most likely be settled there. Texas caps medical malpractice awards at $250,000 for noneconomic losses, such as pain and suffering, and the low caps mean businesses are not particularly afraid of being held liable. In the eyes of the justice system, children like Betty have little economic value, and therefore the value of her life will not exceed the established cap.
The Wattenbargers will never be done asking questions. Holding the piece of floorboard, Stacey told me, “[It’s] splintered and broken, just like our family.” But perhaps there will come a day when they are not constantly haunted. This fall, while on vacation in Cheyenne, Wyoming, Jeremy and Stacey felt at peace for the first time in more than two years. Stacey and Annabelle went shopping at the mall; Stacey’s panic attacks subsided. Jeremy finally recognized what Stacey already knew: Staying in the home where they’d lived with Betty trapped them in the worst day of their lives. After returning to Texas, the couple made an offer on a home an hour and a half away, in Aledo, and by the end of the year had moved into their new home.
As a physician, I know that we are at our most vulnerable when we go to the doctor. We place our trust in the person on the other end of the stethoscope. We place our trust in the system. But the system is being manipulated for financial gain by private equity, corporations, hospitals, greedy physicians, and untrained nonphysicians. Medical error is the third leading cause of death in the United States. A heavy reliance on unsupervised nonphysicians in emergency care settings should raise questions for state and federal regulators and legislators about patient safety. But we are a nation where corporations are king, and corporations are not asking those questions. The Wattenbargers wish they’d known to ask more themselves. For any person reading, the family wishes the same thing I do: When you make your next trip to the urgent care, ask who is staffing it. Your life, or the life of your child, may depend on the answer.