AMSA debate on midlevel scope of practice

[Nymphicus]

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Does anyone have good links, citations, studies, or resources concerning midlevel providers? Specifically NP/DNP and CRNA.

I am going to be in a town-hall debate next week and taking the side that midlevel providers should not have an increased scope of practice (including autonomy) as they do not have the appropriate training.

Also, let me know if you have any suggestions on topic points.

Thanks

 

[SpecterGT260]

A good place to start is the study that showed a 50% failure rate on a watered down USMLE

http://www.ama-assn.org/amednews/2009/06/08/prl10608.htm not the primary source, but I am interested and wanted to contribute something when I should be studying IMO assuming you can defend against retorts and pick apart papers that may favor nurse practice that paper is pretty damning. The USMLE IS the measure by which states determine minimal competency, and even given their clinical "trianing" they still cannot pass a test that most residents pass with a weekend or less worth of review.

 

[SpecterGT260]

http://www.aafp.org/online/etc/medi...le.tmp/NP_Info_FP-NPTraining-Compare-4pgs.pdf

I would REALLY emphasize the CME aspect in this paper. The one thing the general public seems to accurately understand about medicine is the rate at which it is changing. CME requirements are a must to ensure that your DNP isnt treating you with methods he/she learned 20 years ago and are either out of date or dangerous.

another:
http://www.aafp.org/online/etc/medi...ng.Par.0001.File.tmp/NP-Kit-FP-NP-UPDATED.pdf

 

[SpecterGT260]

There are also some AANA papers out that can be destroyed.... the problem is making sure people really understand the shortcomings of their literature and why this means bad news for the patients. Obviously the AANA concludes that CRNAs are "as competent", but their data dont really show that.
Here is one for midwives:

http://www.ncbi.nlm.nih.gov/pubmed/17542818

In their study they say essentially "we gave midwives low risk patients and compared their outcomes to general hospital admissions. In all, doctors were more likely to use intervention methods than midwives (who are unable to anyways, nor would they on their low risk patients), therefore broader use of midwives will reduce physician interventions in childbirths"

So basically: "since we didnt kill more babies in the group where none were going to have difficulty anyways, we probably won't kill any in groups where they may have higher incidence of complications"
You could pair papers like this with method assessment data of the methods they aim to reduce and present the benefit that such interventions bring in terms of saved baby lives. Town halls love saved babies.


The biggest problem of the CRNA papers is they tend to hide their numbers and the ways by which they arrive at conclusions. They do apples to oranges comparisons. One of their biggest papers shows the highers death rate among anesthesiologist-only practices.
HOWEVER: they do not specify how they are calculating this. It looks like they are keeping it at the total number of patients seen rather than normalizing against # of CRNAs and anesthesiologists, which would give a per-practitioner death rate. There are oodles more anesthesiologists. Coupled with the fact that most often patients are pre-screened for simplicity to go to CRNAs.... no sh** the docs are involved with more mortality. They get way more patients and the CRNAs still have on their training wheels. I also didnt see a breakdown of comorbidities that were looked at.... if I decide to take a study break later I will look for a non-AANA paper on the subject, but I feel like I would have known about it by now if it existed.

 

[SpecterGT260]

Here is another
http://www.ncbi.nlm.nih.gov/pubmed/10861159?dopt=abstractplus

upon a quick skim, while older, this paper seems to address the control issues that the AANA papers do not. They could try to claim that CRNA training has improved over the last 12 years.... I would look into their admissions criteria, graduating test scores, and curriculum changes. Because it would be super nifty if they tried that retort and you could produce data that they are full of it.

As a side note: how big is the stage for this debate? are we talking an actual debate/presentation to someone who can influence policy or is this a mock debate deal? No offense, but if it is just for funsies I am gunna get back to studying 🙂

 

[link2swim06]

On the last graph on last page, note that SHORTEST residency for physicians is still FOUR TIMES more education than NPs http://www.aafp.org/online/etc/medi...ng.Par.0001.File.tmp/NP-Kit-FP-NP-UPDATED.pdf


On bread and butter stuff they may be equal to physicians. But their patients are likely screwed if they don't have a common disease.

 

[SpecterGT260]

On the last graph on last page, note that SHORTEST residency for physicians is still FOUR TIMES more education than NPs http://www.aafp.org/online/etc/medi...ng.Par.0001.File.tmp/NP-Kit-FP-NP-UPDATED.pdf


On bread and butter stuff they may be equal to physicians. But their patients are likely screwed if they don't have a common disease.

the problem is that THEY are the ones writing the literature on these things and they always control the patient cohorts to uncomplicated cases and hope nobody notices when they say they are just as good.

The trick will be to find a dozen or so of their papers that do this, pull out/highlight the excerpt that says this, and then look into the type of patients the doctors are being analyzed against. I suspect these are not fair comparisons either. But if it can be shown that they have equal mortality rates on EASIER patients, well....

 

[IlDestriero]

The biggest problem that I see with the broad proliferation of the NP run "doc in the box" minute clinic type places is a total lack of follow up. People come to them as their only "physician". You come in for bursitis get treated, incidentally told your BP is "a little high" and to follow up with your PCP, which you don't actually have. Since you got better, you go another couple years without any treatment for your worsening hypertension. That is until something tragic and avoidable happens. At least if you went to the NP at your primary physicians office, they can work in for your 10 min acute bursitis visit, but also set you up for a 30 min appt for a followup and comprehensive physical. This increased access is an illusion, and it is hurting people.
It won't help your debate though.
One thing you can look for is to look at where the CRNAs are getting their data, what the database is actually for, and if it is even accurate.
Case selection bias is a huge problem with CRNA data and it's completely ignored. It invalidates their conclusions.
If you looked at data from our hospital, the CRNA paper's analysts would say that Solo MDs are the safest, because we do only healthy kids solo in the ASCs, followed by the crna care team model, than a resident care team, and finally, at all costs, you should absolutely refuse to have anything done by an anesthesia fellow/anesthesiologist care team. They're a bunch of assassins and hacks killing and maiming kids every day. Or maybe it has something to do with patient selection. You decide.

 

[wholeheartedly]

A few issues that might warrant scrutiny are lack of standardization across NP curriculum. Different programs have radically different requirements. Show them what courses NP's are required to take, you'll see a lot of mgmt and public health type courses but not a lot of clinical/pathophys/pharmacology type courses. PA curriculum is much more standardized.

Another point is that it used to be that they want several years experience in health related field with direct patient access for applicants to midlevel programs. A lot of NP programs now just let you go straight through without even working as a nurse first. A friend who is a nurse and initially wanted to go NP was telling me about a brand new grad who never worked as an RN who just got a NICU NP position.

Other things include the increasing number of residencies indicating that midlevels are human beings who will go where their interest and the money is instead of filling shortage areas. I read one paper, sorry can't find it now, where an oncology NP actually stated that it was important to refer patients to other NP specialists vs. physician specialists when referring. So patients could get referred to several "specialists" and never see a physician.

 

[Nymphicus]

Thanks for the suggestions guys. I will look into all of these links.

 

[Nymphicus]

Here is another
As a side note: how big is the s... studying I suppose. Thanks for the links.