Freedom of Choice

[deepdish83]

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I'm curious as to why so many people in this forum are opposed to a patients right to choose who they will receive care or health related information from. If people decide they want to receive their care from an NP or PA as opposed to an FP, should that not be a choice they are allowed to make? In every other area of life people are allowed to make choices about what kind of services they wish to receive and who they wish to receive them from. Why should the same not be true of healthcare?

 

[MOHS_01]

😉

Good question -- I don't have a problem with it; the problem (for me) comes with the assertion of equivalence -- when that is an absolute falsehood.

 

[J-Rad]

I'm curious as to why so many people in this forum are opposed to a patients right to choose who they will receive care or health related information from. If people decide they want to receive their care from an NP or PA as opposed to an FP, should that not be a choice they are allowed to make? In every other area of life people are allowed to make choices about what kind of services they wish to receive and who they wish to receive them from. Why should the same not be true of healthcare?

You do realize that this is what is known as a "straw man" argument and that many to most here are intelligent enough to see (through) that, right?

 

[Charles_Carmichael]

I'm curious as to why so many people in this forum are opposed to a patients right to choose who they will receive care or health related information from. If people decide they want to receive their care from an NP or PA as opposed to an FP, should that not be a choice they are allowed to make? In every other area of life people are allowed to make choices about what kind of services they wish to receive and who they wish to receive them from. Why should the same not be true of healthcare?

Just so you know, getting medical care is not like "every other area of life." Getting medical care is not the same going to the store to buy a DVD player. Patients are generally not "informed consumers."

Also, J-Rad is right that what you're proposing is a strawman.

 

[dpmd]

Someone who wants to do hair and nails isn't allowed to just offer those services for pay unless they have received a cosmetology license (meaning they met the standards for obtaining that license and have the knowledge that will allow them to provide safe and hygienic services). If a person wants to go to an unlicensed person they put themselves at risk and that is why the government creates a system where people can readily identify a provider with the appropriate level of training. If that system is in place for something as simple as that why is it a surprise that it is done for health care?

 

[docB]

I don't know if it is a strawman exactly. He's basically alluding to the Libertarian ideal for healthcare where there is a total free market. In that ideal providers charge patients whatever the market will bear without any regulatory interference. And there is a free market of providers, ie. the patients can go to whoever they want for care and there are no licensing or regulatory constraints on the supply side.

I think that the main objection is two fold if you really think about it. First as physicians we chose the profession and were educated with the expectation that we would practice in an environment similar to what we have had, where doctors function in out traditional roles without much fear of competition. A change in that order is alarming.

Second, and more applicable to the laity, is the expectation that some entity (usually the government) has assured a base level of safety and/or quality in the services we purchase. I expect that the McDonalds was inspected by the health department and that the pilot knows what he is doing. Clearly outbreaks of foodborne illness and plane crashes show the fallability of these safeguards but are we really willing to try to vett our own professionals? How could we ever really ensure that we are buying real medications without oversight?

 

[deepdish83]

You do realize that this is what is known as a "straw man" argument and that many to most here are intelligent enough to see (through) that, right?

A. This isn't a strawman as i'm not trying to refute an argument, but rather asking a philosophical question about peoples freedom to choose in the context of healthcare.

B. If I hijacked your thread with a silly strawman argument I would totally understand the need to point it out. Since this isn't your thread, why bother posting if you have nothing to add?

C. If everyone on the board is intelligent enough to recognize a strawman then there is really no reason for you to point it out.

 

[deepdish83]

I think that the main objection is two fold if you really think about it. First as physicians we chose the profession and were educated with the expectation that we would practice in an environment similar to what we have had, where doctors function in out traditional roles without much fear of competition. A change in that order is alarming.

But it is unfair to the patient/consumer to restrict choice on the basis of maintaining a cartel like employment structure. Again why should your desire for job security effect my ability to choose who I receive my healthcare from? It is almost always the case that when competition is artificially removed, the consumers of the good or service suffer, while those who provide it, benefit.

Let me phrase the question differently. "If I want to pay my neighbor for his advice on how to get rid of my cold, should this be allowed?"

I would argue, although this could really get get off track from the initial question, that generally the government does a horrible job at ensuring quality. Especially when compared to the ability of increased competition to drive down costs and increase quality. This can easily be seen in the context of tech companies which are constantly delivering exponential improvements in the cost and quality of their products. Industries that are more tightly regulated and have less competition tend to move at a much slower pace.

 

[docB]

I agree with you for the most part. However I am much more libertarian than most. When I said we expect to be shielded from competition I meant that we jsut expect that, not that it is good or justified in a societal sense.

Now the idea that society has an interest in protecting itself from incompetent or corrupt professionals has more traction. The extremist libertaian ideal that anyone, no matter how untrained or grossly incompetent should be able to practice whatever they want and that the dictum of "buyer beware" should be the only thing keeping them from killing and injuring people is a much harder sell.

 

[JaggerPlate]

Ehh ... too tired.

 

[GH253]

You do realize that this is what is known as a "straw man" argument and that many to most here are intelligent enough to see (through) that, right?

There is no straw man here. To restrict the ability to practice medicine to doctors is to declare that patients do NOT have the right to purchase medical services from anyone other than an MD or DO and to deny them any choice in the matter.

 

[J-Rad]

I'm curious as to why so many people in this forum are opposed to a patients right to choose who they will receive care or health related information from. If people decide they want to receive their care from an NP or PA as opposed to an FP, should that not be a choice they are allowed to make?

I don't claim expertise in logic or logical fallacies, however, here is my rationale for my statement: You made the above statement. The implication ("so many") is that everyone (or near so) believes and has stated that patients' "freedom to choose" is being attacked by [us]. The problem is that very few (almost none to my memory) have made the argument that patients shouldn't be allowed to choose whom they see for care nor have many argued that midlevels shouldn't be allowed to practice (go back, and while you'll find plenty of bemoaning the call for independent practice and for "equivalence" to physicians, but you'll find many caveats that midlevels have an appropriate place in healthcare and have value.) Like DocB, I have a fairly libertarian streak and believe that you and anyone should have the choice to choose whomever you would like for your healthcare. But I do believe in "truth in advertising" and the truth is both objectively and subjectively (i.e. my opinion) is that there is not "equivalence". If you choose your healthcare provider with that in mind, more power to you. The noctor lobby has the right to argue equivalence and we, as physicians, have the right to make the counter-argument. But you leveled your critique at an argument that doesn't really exist. That, to me, is a straw man, or something closely akin.

 

[GH253]

Now the idea that society has an interest in protecting itself from incompetent or corrupt professionals has more traction. The extremist libertaian ideal that anyone, no matter how untrained or grossly incompetent should be able to practice whatever they want and that the dictum of "buyer beware" should be the only thing keeping them from killing and injuring people is a much harder sell.

Any argument which relies on the personification of "society" automatically fails. "Society" is not a person and is incapable of either having interests or protecting itself. This is really about certain self-interested members of society - doctors who want to disrupt competition and politicians who pander to voters by offering "protection" - forcing their preferences on everyone else.

 

[deepdish83]

I don't claim expertise in logic or logical fallacies, however, here is my rationale for my statement: You made the above statement. The implication ("so many") is that everyone (or near so) believes and has stated that patients' "freedom to choose" is being attacked by [us]. The problem is that very few (almost none to my memory) have made the argument that patients shouldn't be allowed to choose whom they see for care nor have many argued that midlevels shouldn't be allowed to practice (go back, and while you'll find plenty of bemoaning the call for independent practice and for "equivalence" to physicians, but you'll find many caveats that midlevels have an appropriate place in healthcare and have value.)

Reread your bolded statement. Preventing certain people from offering independent services is an infringement on consumer choice. You may believe that this infringement is correct and necessary for any number of reasons, but I am interested in knowing why people hold that view.

Like DocB, I have a fairly libertarian streak and believe that you and anyone should have the choice to choose whomever you would like for your healthcare. But I do believe in "truth in advertising" and the truth is both objectively and subjectively (i.e. my opinion) is that there is not "equivalence". If you choose your healthcare provider with that in mind, more power to you. The noctor lobby has the right to argue equivalence and we, as physicians, have the right to make the counter-argument. But you leveled your critique at an argument that doesn't really exist. That, to me, is a straw man, or something closely akin.

The equivalence argument is the perfect example of a straw man. Broken down it would look like this.


Arguement A (NP): NPs have been shown to provide more cost effective care that is equivelent to that provided by MDs. (Cite study x,y,z)

Argument B (strawman) (MD): Since MDs go through many more years of training, equivalence is impossible.

Here argument B, while truthful, misrepresents the position of argument A. If this reasoning was used in any other industry to prove superiority it would be laughed at. If Apple tried to claim that their computers were better designed then HPs, because they hire more engineers at the PhD level no one would consider this a valid reason to buy Apple computers.

 

[Charles_Carmichael]

Medical care is a field that needs to be regulated so that patients can be protected from harm.

I think preventing some people from practicing independently (ie. NPs/DNPs) is perfectly valid since there is no evidence to suggest that their quality of care is equivalent to that of the gold standard (physicians). There are a lot of commonly cited studies, however, with huge flaws in them (not small ones a lot of studies have, but huge, gaping flaws that makes me question the competence/agenda of the authors). Patient satisfaction is not a measure of medical competency, as much as the nursing midlevels seem to think it is. Absence of evidence is not evidence of absence.

Even in the recent AANA propaganda study, didn't one of the study's own tables show that after opting-out, CRNAs had an increase in both complications and mortalities (compared to pre-opt-out)?

Come back to me about "freedom of choice" and "consumer choice infringement" once you've got the results of a prospective trial on hand and we'll talk. Until then, I feel it's perfectly valid to hold health care providers to a high standard and not allow anyone not meeting that standard to practice independently.

 

[Charles_Carmichael]

Arguement A (NP): NPs have been shown to provide more cost effective care that is equivelent to that provided by MDs. (Cite study x,y,z)

The problem, though, is that Argument A itself is wrong. There aren't any valid studies suggesting NPs provide cost effective care that is equivalent to physicians. In fact, some studies have shown that NPs order more tests and refer out more, suggesting that they, in fact, cost the system more money than physicians do. Additionally, the current studies measuring "outcomes" put heavy emphasis on patient satisfaction. Surely you're not saying that patient satisfaction = competence? The best done study so far looked at cookie cutter medicine where the only thing providers had to do was follow a protocol (that one can argue requires no training at all) and lasted only 6 months. The reason it was stopped after 6 months was because the author, Mary Mundinger (the leading proponent of DNP equivalency to physicians), knew that with such a short study, no differences in outcomes will be seen.

So, now, in the absence of evidence, the arguments change to:

Arguement A (NP): While there is no substantial evidence to suggest that nursing midlevels are more cost effective than physicians nor that they have equivalent outcomes, NPs should be allowed to practice independently because they "streamlined" physician training.

Argument B (MD): Since MDs go through many more years of training, that doesn't make any sense. You literally cannot condense 7+ years of training into 2-3 years and still expect to graduate students of the same caliber.

As you can see, there's no strawman there. By using logic, we're arguing that NPs/DNPs shouldn't practice independently. If medical students at the end of third year are not allowed to practice independently, even though they have more basic science training and more clinical hours than nursing midlevels, it logically follows that someone with lesser training than the M3 (ie. NPs/DNPs) should not be allowed to practice independently either.

 

[docB]

Let me clarify that I don't think that J-Rad was wrong with his label of strawman. The classic strawman is a scenario so extreme that it is hoped that it will scare the subject into fear of even more moderate possibilities (similar in effect to reductio ad absurdum but opposite in scope). The reason I said this may not be a typical strawman is that it isn't just a silly hypothetical, it's the actual ideal of the libertarian philosophy.

Any argument which relies on the personification of "society" automatically fails. "Society" is not a person and is incapable of either having interests or protecting itself. This is really about certain self-interested members of society - doctors who want to disrupt competition and politicians who pander to voters by offering "protection" - forcing their preferences on everyone else.

I disagree. I think that "society" does exist and that its members can agree on principles that they want to abide by because they think it is in their best interest. As a conservative I think that the fewer things we agree to abide by the better. Once you have taken libertarianism to the extreme of saying that there is no instance where society should act collectively you have advocated anarchy. That's the clear result of a philosophy that denies "society" any authority.

There is no straw man here. To restrict the ability to practice medicine to doctors is to declare that patients do NOT have the right to purchase medical services from anyone other than an MD or DO and to deny them any choice in the matter.

That is correct. They have been denied the option of buying medical professional services from anyone who is not licensed. Your solution to this is to eliminate licensure and allow a totally free market. Another solution that is consistent with extreme libertarianism would to suggest that anyone who finds this society too restrictive can certainly leave and seek care in a country that does not require medical licensure.

Reread your bolded statement. Preventing certain people from offering independent services is an infringement on consumer choice. You may believe that this infringement is correct and necessary for any number of reasons, but I am interested in knowing why people hold that view.

I will be happy to explain why I do not support a completely free market on the supply side of medical professional services. I do think that there are some things that should be done at the societal level. Infrastructure and defense are the main items. As a part of infrastructure society has an interest in requiring a base level of competence in its physicians. If we allowed anyone who wished to practice to do so at the peril of their patients and the only safeguard we imposed was the dictum of let the buyer beware people would be hurt. Productive members of society would be rendered useless. Therefore I believe it is an acceptable loss of personal liberty to require licensure of physicians or anyone who wants to act as a physician.

 

[GH253]

The problem, though, is that Argument A itself is wrong. There aren't any valid studies suggesting NPs provide cost effective care that is equivalent to physicians. In fact, some studies have shown that NPs order more tests and refer out more, suggesting that they, in fact, cost the system more money than physicians do. Additionally, the current studies measuring "outcomes" put heavy emphasis on patient satisfaction. Surely you're not saying that patient satisfaction = competence? The best done study so far looked at cookie cutter medicine where the only thing providers had to do was follow a protocol (that one can argue requires no training at all) and lasted only 6 months. The reason it was stopped after 6 months was because the author, Mary Mundinger (the leading proponent of DNP equivalency to physicians), knew that with such a short study, no differences in outcomes will be seen.

So, now, in the absence of evidence, the arguments change to:

Arguement A (NP): While there is no substantial evidence to suggest that nursing midlevels are more cost effective than physicians nor that they have equivalent outcomes, NPs should be allowed to practice independently because they "streamlined" physician training.

Argument B (MD): Since MDs go through many more years of training, that doesn't make any sense. You literally cannot condense 7+ years of training into 2-3 years and still expect to graduate students of the same caliber.

As you can see, there's no strawman there. By using logic, we're arguing that NPs/DNPs shouldn't practice independently. If medical students at the end of third year are not allowed to practice independently, even though they have more basic science training and more clinical hours than nursing midlevels, it logically follows that someone with lesser training than the M3 (ie. NPs/DNPs) should not be allowed to practice independently either.

This is a molestation of logic. The argument is that ANYONE should be able to practice regardless of his level of training. Third year medical students should be able to practice independently, just as NPs and PAs should be able to.

Restricting market entry is NEVER about protecting the public. Instead, it is always about protecting the lobbyist's monopoly. Realize that licensing laws are established by political groups like the AMA who falsely claim to represent an entire profession. The policies they support are designed to protect their own interests, not the interests of patients nor even the interests of the doctors they claim to represent.

Your studies are irrelevant. This is a philosophical issue, not a scientific one. The question is not whether non-physician practitioners can be shown to provide equivalent services. Instead, the question is this: do free human beings have the moral right to choose who they want to patronize for medical care, or do politicians and lobbyists have the right to force their will on everyone else?

 

[hurdlepup]

This is a molestation of logic. The argument is that ANYONE should be able to practice regardless of his level of training. Third year medical students should be able to practice independently, just as NPs and PAs should be able to.

Restricting market entry is NEVER about protecting the public. Instead, it is always about protecting the lobbyist's monopoly. Realize that licensing laws are established by political groups like the AMA who falsely claim to represent an entire profession. The policies they support are designed to protect their own interests, not the interests of patients nor even the interests of the doctors they claim to represent.

Your studies are irrelevant. This is a philosophical issue, not a scientific one. The question is not whether non-physician practitioners can be shown to provide equivalent services. Instead, the question is this: do free human beings have the moral right to choose who they want to patronize for medical care, or do politicians and lobbyists have the right to force their will on everyone else?

This is basically a political theory conversation then. How about quoting some Locke, Hobbes, etc???

I personally don't want to live in anarchy, and am perfectly happy to refuse "snake oil" sales(wo)men. Even if it is a disclaimer like, "The FDA doesn't approve this!" written in big letters.

Or "Good for managing your care, but needs supervision and diagnosis by by a physician" on the license and advertisements of NPs.

These are things that I want society to have in place for me, as I go to see the doctor when I am ill--I don't particularly have time to personally investigate the medical training of every doc I might see, so I am glad there is a national body to do such a thing.

 

[Charles_Carmichael]

This is a molestation of logic. The argument is that ANYONE should be able to practice regardless of his level of training. Third year medical students should be able to practice independently, just as NPs and PAs should be able to.

I already made it clear why I don't think that just anyone should be allowed to practice.

Restricting market entry is NEVER about protecting the public. Instead, it is always about protecting the lobbyist's monopoly. Realize that licensing laws are established by political groups like the AMA who falsely claim to represent an entire profession. The policies they support are designed to protect their own interests, not the interests of patients nor even the interests of the doctors they claim to represent.

This is where you're wrong. Getting medical care is not like choosing to buy a DVD player or a soda. By choosing Sony over Panasonic, the consumer is not gaining an increased risk of injury/death. However, when it comes to medical providers, if a patient sees one who doesn't have adequate training, that patients runs a significantly higher risk or injury/death than if they had seen someone who went through a rigorous training.

I think medical professionals need to be regulated precisely because the regulation will protect patients from providers who don't meet a standard. Without this safety net, it will be the patients, and society itself, who suffer. I, for one, am more than happy to give up the freedom of choice when it comes to health care providers in exchange for a high standard. And I bet most people are as well.

Your studies are irrelevant. This is a philosophical issue, not a scientific one. The question is not whether non-physician practitioners can be shown to provide equivalent services. Instead, the question is this: do free human beings have the moral right to choose who they want to patronize for medical care, or do politicians and lobbyists have the right to force their will on everyone else?

The studies are relevant. It's much more of a scientific issue than a philosophical one because any missteps will result in serious public harm. The question to ask is whether non-physicians can provide services at the same quality as physicians do. The public is not crying out for free choice of health care providers. The only ones making this "freedom of choice" argument are the nursing midlevels. The public, through their representatives, established a high standard that one needs to meet before being allowed to practice because they realize that anything less has the potential to be dangerous. docB explained pretty well on why medical professional services shouldn't be a free market.

Edit: Additionally, a lot of times, the patient doesn't have a choice on who they're going to see. In a car accident? Unconscious? Some other trauma? Are you really going to stop and think which health care provider you want to see or are you going to want to be rushed to the hospital as quickly as possible and be taken care of by the provider with the highest level of training?

 

[GH253]

This is basically a political theory conversation then. How about quoting some Locke, Hobbes, etc???

I personally don't want to live in anarchy, and am perfectly happy to refuse "snake oil" sales(wo)men. Even if it is a disclaimer like, "The FDA doesn't approve this!" written in big letters.

Or "Good for managing your care, but needs supervision and diagnosis by by a physician" on the license and advertisements of NPs.

These are things that I want society to have in place for me, as I go to see the doctor when I am ill--I don't particularly have time to personally investigate the medical training of every doc I might see, so I am glad there is a national body to do such a thing.

So, in other words, because you're too stupid and lazy to check a doctor's credentials, everyone else should forfeit their autonomy in order to accommodate your refusal to think. And your wanting it is the only justification necessary.

This way of thinking - or, more accurately, this total absence of thought - is a far greater danger to society than the incompetence of untrained medical personnel. Such lack of intellectual independence, and willingness to accept government decree as a substitute for one's own rational judgment, is exactly what turns credentialed "experts" into the real hacks from whom society needs protection.

 

[MOHS_01]

So, in other words, because you're too stupid and lazy to check a doctor's credentials, everyone else should forfeit their rights in order to accommodate your refusal to think. And your wanting it is the only justification necessary.

Your way of thinking - or, more accurately, your total absence of thought - is far more dangerous than the incompetence of any medical hack. This lack of intellectual independence and willingness to accept ideas on the authority of a governing body is exactly what is responsible for turning credentialed "experts" into hacks....

👍

Yep... it is always easier to let someone else do the work for you.

 

[deepdish83]

Medical care is a field that needs to be regulated so that patients can be protected from harm.

People are allowed to make all sorts of choices that could potentially cause them harm. In fact most things in life have the potential to cause harm so it is easy to make this generic statement.

Industry X is a field that needs to be regulated so that people can be prevented from harm

Do you believe that the government should regulate all activities that may cause people harm?

I think preventing some people from practicing independently (ie. NPs/DNPs) is perfectly valid since there is no evidence to suggest that their quality of care is equivalent to that of the gold standard (physicians). There are a lot of commonly cited studies, however, with huge flaws in them (not small ones a lot of studies have, but huge, gaping flaws that makes me question the competence/agenda of the authors). Patient satisfaction is not a measure of medical competency, as much as the nursing midlevels seem to think it is. Absence of evidence is not evidence of absence.

First of all there is a fairly substantial body of literature that compares NP vs MD care. I understand that many of the studies may have flaws, however dismissing the entire body as a whole is a bit disingenuous. Have you read all of the papers? If the flaws are really as glaring as you make them out to be, how did the studies ever make it into journals like the JAMA. You act as though these are all op-ed pieces in a small town newspaper. I'm hoping you can provide the readers of this thread with at least a meta-analysis or a link to an objective analysis showing why the 20+ papers are completely irrelevant to the argument.

Come back to me about "freedom of choice" and "consumer choice infringement" once you've got the results of a prospective trial on hand and we'll talk. Until then, I feel it's perfectly valid to hold health care providers to a high standard and not allow anyone not meeting that standard to practice independently.

Again you are missing the point of freedom of choice. Choice means that I'm allowed to make up my own mind on what is best for me for better or worse. I can choose to eat unhealthy and not exercise if I want, even though 100s of trials and studies have shown it will have a large negative effect on my health.

 

[deleted89854]

You can choose to eat whatever you want, but the reason your McDonalds is free from 20 different strains of E Coli (or at least it should be) is that there is a federal agency that regulates the production of food and the cleanliness of the facility it's provided in. To use a more recent example, by your logic we should allow the sale of Salmonella tainted eggs since people should be free to decide if they want to eat them or not. Industry cannot reliably be expected to police itself.

You are lacking citations for these studies you speak of. I doubt you have read them. If you are the one making claims of equivalence, perhaps you should.

 

[GH253]

You can choose to eat whatever you want, but the reason your McDonalds is free from 20 different strains of E Coli (or at least it should be) is that there is a federal agency that regulates the production of food and the cleanliness of the facility it's provided in.

This statement is so evil I can barely stand to respond to it.

A restaurant chain wants to make money. To that end, they need patrons to return to the establishment in the future. They do not generate repeat business by poisoning and killing their customers! Because their survival depends above all else on keeping their food safe, their very existence demands that they MUST police themselves in order to avoid going under.

A mistake of this sort is not made innocently; it reflects a malevolent view of the world and a malevolent view of human beings in general. Your goal is simply to demonize others, not to support a rational conclusion. It disgusts me that there are practicing physicians who actually think like this.

 

[deepdish83]

You can choose to eat whatever you want, but the reason your McDonalds is free from 20 different strains of E Coli (or at least it should be) is that there is a federal agency that regulates the production of food and the cleanliness of the facility it's provided in.

Yes because without the USDA McDonalds would be serving Ecoli ridden burgers to all their customers. In 1993 Jack in the Box sold meat contaminated with Ecoli. Take note that this happened while being regulated by our great federal agencies. After losing millions in sales, and even more money in lawsuits JITB was near to bankruptcy. It was a public relations nightmare that almost killed their company. Industry can and does reliably police itself to prevent against its own destruction.

To use a more recent example, by your logic we should allow the sale of Salmonella tainted eggs since people should be free to decide if they want to eat them or not. Industry cannot reliably be expected to police itself.

No this is a poor example. Of course I don't support the sale of food products that are knowingly infected with harmful bacteria. Here is a better example.

I enjoy eating raw eggs, very rare steak, and sushi. Eating all of these have been shown to increase my risk of food borne illness, and could potentially have negative effects on my health. Since a great number of people in our society enjoy eating eating undercooked meat, allowing this practice could cause harm to the consumer and society as a whole. Do you believe the government should forcibly regulate my choice to eat a rare hamburger?

 

[Charles_Carmichael]

People are allowed to make all sorts of choices that could potentially cause them harm. In fact most things in life have the potential to cause harm so it is easy to make this generic statement.

Industry X is a field that needs to be regulated so that people can be prevented from harm

Do you believe that the government should regulate all activities that may cause people harm?

I don't believe that the government should regulate all activities that may cause people harm. I do believe that the someone should regulate activities that have the potential to cause harm to others (not yourself). I don't care if you choose to punch yourself in the face all day. I do care if you decide to punch someone else in the face. That's when I want someone stepping in.

First of all there is a fairly substantial body of literature that compares NP vs MD care. I understand that many of the studies may have flaws, however dismissing the entire body as a whole is a bit disingenuous. Have you read all of the papers? If the flaws are really as glaring as you make them out to be, how did the studies ever make it into journals like the JAMA. You act as though these are all op-ed pieces in a small town newspaper. I'm hoping you can provide the readers of this thread with at least a meta-analysis or a link to an objective analysis showing why the 20+ papers are completely irrelevant to the argument.

I actually have read the majority of those studies. The questions is, have you? Many nursing midleves cite studies without having read anything further than the abstract. Unfortunately, the abstract doesn't tell you much about methodology.

You also realize that JAMA isn't really that great of a journal right? It seems to publish anything and everything to get some splash coverage. I'm guessing you're referring to the Mundinger study that nursing midlevels seem to think is the greatest thing on earth:

http://www.ncbi.nlm.nih.gov/pubmed/10632281?dopt=Abstract

One of their main outcome measures was patient satisfaction surveys. Like I mentioned previously, satisfaction surveys are a bad way to asses medical competency. Just because people are satisfied with me doesn't mean that I provided good medical care. Also, why did they measure diastolic value? That makes absolutely no sense. They took a value that is pretty much meaningless and found a statistical significance for it. Clearly that's a mark of a scientific study. The fact that they're finding statistical significance in a useless marker does NOT imply equal outcomes. The worst part of the "study" is that it lasts only 6 months! I'm not even trained in medicine and, even to me, 6 months is far too short of a time period to see anything meaningful (not that I'm saying the rest of the study design was adequate). What it seems to me like is that Mundinger intentionally designed the study in this manner because it's the only way for her to show "equivalent" outcomes. That's just bad science there.

This study is actually a perfect example of how NOT to do a study. It's a pretty poorly designed study and the fact that you posted it thinking it proved equal outcomes shows that you don't understand how studies are designed or interpreted. I recommend that you learn to do this rather than depend on other people to tell you what the results of a study are.

Even though they say in the paper that they will come back and look in 2 years to find equivalency, they never did. Look through all the issues of JAMA; they never get back to it. Instead they publish in the high impact factor, widely read, highly regarded "Medical Care Research and Review" (http://mcr.sagepub.com/cgi/content/abstract/61/3/332). They basically didn't have enough follow up to publish a meaningful study.

How about this "wonderful" meta-analysis:

http://www.bmj.com/content/324/7341/819.full

It even mentions in the paper that a lot of the studies were of poor quality. Once again, it looks at patient satisfaction (a useless measure). Not only that, the study also says:

"None of the studies in our review was adequately powered to detect rare but serious adverse outcomes. Since one important function of primary care is to detect potentially serious illness at an early stage, a large study with adequate length of follow up is now justified. "

Since a meta-analysis is only as strong as the studies it looks at, I'm going to have to say that this is a pretty useless meta-analysis.

So yea, I'm going to stand by my statement that the "fairly substantial body of literature that compares NP vs MD care" is a pretty crappy body of literature. It's bad enough to make me question the competence of these "researchers." Either they don't have much of an understanding of statistics and experimental design or they're purposefully trying to mislead others. Either way, that's bad.

Again you are missing the point of freedom of choice. Choice means that I'm allowed to make up my own mind on what is best for me for better or worse. I can choose to eat unhealthy and not exercise if I want, even though 100s of trials and studies have shown it will have a large negative effect on my health.

Bad example there. You can choose to eat unhealthy if you want because you're only hurting yourself there, not others. However, when you start practicing voodoo medicine, you put others at risk. There's a big difference there. Choose to harm yourself all you want. But the moment you start to knowingly put others at risk (due to lack of training), I think someone needs to step in to regulate.

 

[Charles_Carmichael]

No this is a poor example. Of course I don't support the sale of food products that are knowingly infected with harmful bacteria. Here is a better example.

I enjoy eating raw eggs, very rare steak, and sushi. Eating all of these have been shown to increase my risk of food borne illness, and could potentially have negative effects on my health. Since a great number of people in our society enjoy eating eating undercooked meat, allowing this practice could cause harm to the consumer and society as a whole. Do you believe the government should forcibly regulate my choice to eat a rare hamburger?

Actually, it's you who's using poor examples. When you're providing medical care, you're putting others at risk. When you decide to eat raw food, you're putting only yourself at risk. There's a big difference there. When you decide to provide medical care for others without adequate training, you are knowingly putting others at risk. And you yourself say you don't support knowingly putting others at risk. So, I guess we agree then.

 

[MOHS_01]

You can choose to eat whatever you want, but the reason your McDonalds is free from 20 different strains of E Coli (or at least it should be) is that there is a federal agency that regulates the production of food and the cleanliness of the facility it's provided in. To use a more recent example, by your logic we should allow the sale of Salmonella tainted eggs since people should be free to decide if they want to eat them or not. Industry cannot reliably be expected to police itself.

You are lacking citations for these studies you speak of. I doubt you have read them. If you are the one making claims of equivalence, perhaps you should.

You know, perhaps it is not in your best interest to believe whatever line of BS lies they feed you.... especially if that BS is being fed by the hand of the holder of a monopolistic right to the use of force.

 

[ReineAshe]

Yes because without the USDA McDonalds would be serving Ecoli ridden burgers to all their customers. In 1993 Jack in the Box sold meat contaminated with Ecoli. Take note that this happened while being regulated by our great federal agencies. After losing millions in sales, and even more money in lawsuits JITB was near to bankruptcy. It was a public relations nightmare that almost killed their company. Industry can and does reliably police itself to prevent against its own destruction.

Um, do you realize that your evidence makes the argument for the exact opposite of your case? If industry could regulate itself, Jack In The Box never would have happened. After all, it could have overcome the weak regulations, regulated itself, and prevented the disaster -- right?

Ultimately, I seriously doubt any industry could ever regulate itself because of the banality of evil. (Zimbardo, PG. The Lucifer Effect: Understanding How Good People Turn Evil. New York, NY: Random House; 2007.)

No this is a poor example. Of course I don't support the sale of food products that are knowingly infected with harmful bacteria. Here is a better example.

I enjoy eating raw eggs, very rare steak, and sushi. Eating all of these have been shown to increase my risk of food borne illness, and could potentially have negative effects on my health. Since a great number of people in our society enjoy eating eating undercooked meat, allowing this practice could cause harm to the consumer and society as a whole. Do you believe the government should forcibly regulate my choice to eat a rare hamburger?

You just described France. Actually, make that half of the EU. (Well, minus the sushi part.)

They (do I count yet?) do just fine. Is anyone aside from me wondering why?

I'm pretty sure it has nothing to do with libertarianism....

 

[countingdays]

People CAN see NPs and PAs. What the heck are you talking about?

Doctors would limit periprofessional practice because Medicine is a profession. We establish a standard of education that is necessary to enter our profession.

NPs and PAs represent a race to the bottom. Do you think the right amount of education is just barely enough to be able to follow a protocol created by a doctor without harming too many patients?

Do you want to see just how little education you can have before tons of people die? Do you think we should just start cutting one month of NP or PA school each year and following the graduates to see at what point patients have noticeably worse outcomes? Apparently, the absolute minimum and cheapest education is the right amount.

We are an ancient profession and you are undermining it. Why can't you get that?

I'm sure nurses are opposed to letting high school grads get jobs as nurses. Why? What study demonstrates that outcomes are worse?

 

[ReineAshe]

People CAN see NPs and PAs. What the heck are you talking about?

In theory, yes. In practice, it depends on what state you happen to be in, and what the requirements of "under a physician's supervision" or "collaborative agreement" happens to mean in that state. If it means "work in the same office, see a doctor for five minutes to double check, and be covered by the doc's med mal insurance," then maybe not so much.

NPs and PAs represent a race to the bottom.

Bottom of what? Patient care, physician prestige, what?

Do you think the right amount of education is just barely enough to be able to follow a protocol created by a doctor without harming too many patients?

I don't know if you're a woman or not, but go to a Planned Parenthood sometime and make an appointment with their NP. Tell them you have a history of migraine with aura and ask for the pill. See what happens.

I've never seen a NP or PA prescribe something off-label, something with known adverse interactions, etc. Yet I've seen more physicians than I can count prescribe medications off-label, despite known adverse interactions. Hell, just this week my boyfriend saw one doc prescribe Depakote to a teenaged epilepsy patient who tried to commit suicide after taking Topamax, despite the patient telling the doctor she was pretty sure Depakote was in the same drug class and thus shouldn't be prescribed!

Frankly, I'm far more worried about physicians who believe their license entitles them to prescribe off-label. (And let's face it, "off-label" is an euphemism for "without scientific evidence.") You can get away with it because med mal attorneys are a dying breed, but people aren't stupid. They're already starting to view certain types of MDs as unscientific cowboys bought and paid for by Big Pharma.

I suspect certain types of NPs and PAs will ultimately be preferred, in large part, because they're trained to stick to the science.

We are an ancient profession and you are undermining it. Why can't you get that?

I'm not so sure about that -- and I'm pretty sure Paul Starr, Rosemary Stevens, and Charles Rosenberg would agree with me on that one.

 

[MOHS_01]

..Frankly, I'm far more worried about physicians who believe their license entitles them to prescribe off-label. (And let's face it, "off-label" is an euphemism for "without scientific evidence.") You can get away with it because med mal attorneys are a dying breed, but people aren't stupid. They're already starting to view certain types of MDs as unscientific cowboys bought and paid for by Big Pharma.

I suspect certain types of NPs and PAs will ultimately be preferred, in large part, because they're trained to stick to the science. ..

0 - /ignore in 5 posts.... new record.😱

For the record, noob, off-label applications are the only available treatments for a wide variety of conditions.... and cookbook medicine is not the panacea the ignorant and uninitiated believe. 👎

 

[deepdish83]

Um, do you realize that your evidence makes the argument for the exact opposite of your case? If industry could regulate itself, Jack In The Box never would have happened. After all, it could have overcome the weak regulations, regulated itself, and prevented the disaster -- right?

Ultimately, I seriously doubt any industry could ever regulate itself because of the banality of evil. (Zimbardo, PG. The Lucifer Effect: Understanding How Good People Turn Evil. New York, NY: Random House; 2007.)

Neither the government nor industry is infallible. I'm not claiming that mistakes will never happen, rather I'm saying that companies have a much stronger interest in ensuring they don't poison their customers then the government does as their very survival depends on keeping their customers happy and satisfied.

 

[countingdays]

In theory, yes. In practice, it depends on what state you happen to be in, and what the requirements of "under a physician's supervision" or "collaborative agreement" happens to mean in that state. If it means "work in the same office, see a doctor for five minutes to double check, and be covered by the doc's med mal insurance," then maybe not so much.



Bottom of what? Patient care, physician prestige, what?

I don't know if you're a woman or not, but go to a Planned Parenthood sometime and make an appointment with their NP. Tell them you have a history of migraine with aura and ask for the pill. See what happens.

I've never seen a NP or PA prescribe something off-label, something with known adverse interactions, etc. Yet I've seen more physicians than I can count prescribe medications off-label, despite known adverse interactions. Hell, just this week my boyfriend saw one doc prescribe Depakote to a teenaged epilepsy patient who tried to commit suicide after taking Topamax, despite the patient telling the doctor she was pretty sure Depakote was in the same drug class and thus shouldn't be prescribed!

Frankly, I'm far more worried about physicians who believe their license entitles them to prescribe off-label. (And let's face it, "off-label" is an euphemism for "without scientific evidence.") You can get away with it because med mal attorneys are a dying breed, but people aren't stupid. They're already starting to view certain types of MDs as unscientific cowboys bought and paid for by Big Pharma.

I suspect certain types of NPs and PAs will ultimately be preferred, in large part, because they're trained to stick to the science.

I'm not so sure about that -- and I'm pretty sure Paul Starr, Rosemary Stevens, and Charles Rosenberg would agree with me on that one.

That's not what off-label means at all.

Telling stories about planned parenthood and listing some names is hardly strong evidence.

You know what I mean by race to the bottom. It means doing the absolute minimum to get by when it comes to training medical personel. Why don't you address my question instead of just telling meaningless stories?
Do you think the goal in medical education should be to determine the absolute minimum education required to take care of patients and to give unlimited practice rights to the minimum achievers?

By supporting NPs and PAs independent practice, you are basically saying the minimum is fine. Think about this: Everything you do with your physician-prepared nursing protocols could be done better by a computer and a physical exam technician. Nurses are so proud that they can follow protocols. A computer can follow a protocol perfectly. Do you think patients' freedom of choice should include using a computer program to self-diagnose and treat?

You are an unnecessary middle man if all you do is follow protocols. Your argument for freedom of choice is self-serving, not a true appeal for freedom.

 

[Charles_Carmichael]

I don't think it's fair to lump PAs with NPs/DNPs. The training PAs receive, in my opinion, is far superior to that of the nursing midlevels (more basic science training, more clinical hours, fewer "fluff" courses like nurse activism, health policy, business administration, etc). Yet, you don't see them pushing aggressively for equivalent scope of practice as physicians. The only reason NPs can practice independently in some states is because of their powerful nursing lobby, not due to their training.

 

[ReineAshe]

0 - /ignore in 5 posts.... new record.😱

For the record, noob, off-label applications are the only available treatments for a wide variety of conditions....

Re-read the post. 🙄

I'm not talking about situations where off-label applications are the only available treatments. It's why I mentioned birth control, migraines, and epilepsy -- three things with a wide variety of options. Even those of us outside of medicine know that.

and cookbook medicine is not the panacea the ignorant and uninitiated believe. 👎

So following good science isn't a good way to prevent unnecessary deaths? Doesn't that suggest that science is irrelevant? If so, then why see a physician at all? 😕

I'm not quite sure I understand your argument. I thought it was this: doctors should be able to limit NP and PAs because (a) they know more science and (b) science saves lives. Yet when I pointed out that doctors are losing respect with the public because of their willingness to use more expensive meds off-label when cheaper, safer, and more effective meds are available that have been explicitly approved for the purpose, you respond with personal attacks and some irrelevant remark about something I didn't address.

So I'm starting to suspect that your logic doesn't resemble our Earth logic.

 

[Charles_Carmichael]

So following good science isn't a good way to prevent unnecessary deaths? Doesn't that suggest that science is irrelevant? If so, then why see a physician at all? 😕

The problem with following protocols (based on my limited understanding) is that patients don't always fit perfectly into the protocol. If it were that easy, we might as well have computers do it. From talking to various residents/attendings, what I understood was that a lot times, even when protocols are in place, a fair bit of clinical judgment needs to be exercised.

So, blindly following protocols doesn't sound like a good idea. They seem to be in place to act more like guidelines rather than explicit instructions. And when patients don't fit the textbook, the training and experience of the provider play a very important role.

I'm not quite sure I understand your argument. I thought it was this: doctors should be able to limit NP and PAs because (a) they know more science and (b) science saves lives. Yet when I pointed out that doctors are losing respect with the public because of their willingness to use more expensive meds off-label when cheaper, safer, and more effective meds are available that have been explicitly approved for the purpose, you respond with personal attacks and some irrelevant remark about something I didn't address.

I have no clue what you're talking about here. What do you mean off-label? Do you mean illegal medications? And where's your evidence for saying that doctors are losing respect because they are more willing to use more expensive meds (that doesn't even make sense). I would argue otherwise actually. There have been several articles recently (one by Dr. Pauline Chen in the NYT comes to mind) about physicians becoming more educated in prescribing generic drugs rather than name-brands in order to help their patients save money.

 

[Stitch]

0 - /ignore in 5 posts.... new record.😱

For the record, noob, off-label applications are the only available treatments for a wide variety of conditions.... and cookbook medicine is not the panacea the ignorant and uninitiated believe. 👎

Absolutely true. If you don't understand this you're probably not even remotely involved in medicine. Most drugs prescribed in peds are off label, and if we didn't prescribe them, then we'd have no treatments at all. This scenario is true in many other practices as well.

Way to talk about something you clearly have no idea about. 👍

 

[MOHS_01]

Re-read the post. 🙄

OK sweat pea, I'll play. Here's what you wrote:

....
Frankly, I'm far more worried about physicians who believe their license entitles them to prescribe off-label. (And let's face it, "off-label" is an euphemism for "without scientific evidence.") You can get away with it because med mal attorneys are a dying breed, but people aren't stupid. They're already starting to view certain types of MDs as unscientific cowboys bought and paid for by Big Pharma.

I suspect certain types of NPs and PAs will ultimately be preferred, in large part, because they're trained to stick to the science.

Now how exactly does the below follow in your "Earth logic"???

I'm not talking about situations where off-label applications are the only available treatments. It's why I mentioned birth control, migraines, and epilepsy -- three things with a wide variety of options. Even those of us outside of medicine know that.

...but at least now you're getting at something with merit -- it's not necessarily that you are ignorant or anything short of a genius; it's simply a case of you stepping beyond the confines of your knowledge. It happens. A lot. Hell, look at our President....

So following good science isn't a good way to prevent unnecessary deaths? Doesn't that suggest that science is irrelevant? If so, then why see a physician at all? 😕

No sweet pea, not always -- nice straw man though. 😉 Sometimes the "science" is really not that good while at other times it simply does not exist. If cookie cutter algorithmic medicine were all that great you would only need a provider for the purpose of the technician...

I'm not quite sure I understand your argument.

I can see that. It's OK....

I thought it was this: doctors should be able to limit NP and PAs because (a) they know more science and (b) science saves lives. Yet when I pointed out that doctors are losing respect with the public because of their willingness to use more expensive meds off-label when cheaper, safer, and more effective meds are available that have been explicitly approved for the purpose, you respond with personal attacks and some irrelevant remark about something I didn't address.

Cannot remember ever making any such argument.... but, be that as it may, let's look at it all the same. Inherent in this assumption is that encyclopedic knowledge is all that is necessary or involved in clinical medicine; this is an assumption out of lack of experience and actual knowledge of the practice of medicine -- and a rather common one. Everyone who has gone through the gauntlet of medical education knows at least one person who is a virtual encyclopedia of trivial knowledge and statistics.... yet this person often has significant difficulty with the actual practice of medicine as things do not always fit neatly into the binomial algorithmic mechanism of thought. Patterns and patients are often complex... and do not lend themselves well to the latest volume of the Compendium (or Wiki... or Google... or the support forums...).

 

[MOHS_01]

Absolutely true. If you don't understand this you're probably not even remotely involved in medicine. Most drugs prescribed in peds are off label, and if we didn't prescribe them, then we'd have no treatments at all. This scenario is true in many other practices as well.

Way to talk about something you clearly have no idea about. 👍

About all of derm is off label -- the numbers simply are not there to justify the costs of the BS FDA process (so that some pseudo-intellectual can feel safe with the "science" behind it all)....

 

[hurdlepup]

So, in other words, because you're too stupid and lazy to check a doctor's credentials, everyone else should forfeit their autonomy in order to accommodate your refusal to think. And your wanting it is the only justification necessary.

This way of thinking - or, more accurately, this total absence of thought - is a far greater danger to society than the incompetence of untrained medical personnel. Such lack of intellectual independence, and willingness to accept government decree as a substitute for one's own rational judgment, is exactly what turns credentialed "experts" into the real hacks from whom society needs protection.

No, actually, its because I am too busy with medical school to have time for much of anything else.

Frankly, your lack of ability to conduct rational discourse without resorting to petty name calling just made this conversation enter the "not worth my time" status.

Ignore status entered.

 

[ReineAshe]

That's not what off-label means at all.

Last time I checked, different sentences and different paragraphs responding to different quotes can mean different things. In one paragraph I'm talking about off-label scripts; at another point I'm talking about an organization with a blanket policy concerning its NPs prescribing for a contraindication; at a third point I'm talking about a contraindication that arguably rises to the level of medical malpractice.

Telling stories about planned parenthood and listing some names is hardly strong evidence.

PP explicitly says it won't prescribe it for patients with migraine with aura on its website: plannedparenthood.org/health-topics/birth-control/birth-control-pill-4228.htm. If you don't believe me, call and ask.

While the name happened this week I can't mention, how many med mal cases involving SSRIs have you heard of that operate along the same lines?

You know what I mean by race to the bottom. It means doing the absolute minimum to get by when it comes to training medical personel.

But at least they'll be medical personnel -- which is actually a step up from our current position, at least for patients. I don't see how an improvement is "a race to the bottom."

If there is a race to the bottom, it's not the one you claim it is. So if you're still worried, it's about something other than patients.

Why don't you address my question instead of just telling meaningless stories?

Re-read my post: I did. Atul Gawande did as well. Not coincidentally, we both did it with vignettes.

Do you think the goal in medical education should be to determine the absolute minimum education required to take care of patients and to give unlimited practice rights to the minimum achievers?

Wowza. Strawman much?

Where did I say anything about minimum educations? Or minimum achievers? Or unlimited practice rights?

By supporting NPs and PAs independent practice, you are basically saying the minimum is fine.

(1) So you're saying that you've really done an exhaustive survey of the medical, NP and PA licensing standards in all 50 states?

(2) Disagreeing with you =/= Supporting NPs and PAs. To tell you the truth, I don't really have an opinion. I just get the feeling this debate is fundamentally about something else, in much the same way that abortion really has nothing to do with either choice or life.

Think about this: Everything you do with your physician-prepared nursing protocols could be done better by a computer and a physical exam technician. Nurses are so proud that they can follow protocols. A computer can follow a protocol perfectly. Do you think patients' freedom of choice should include using a computer program to self-diagnose and treat?

I do. They've had that for psychology since I got my first copy of Debian when I was in elementary school. If you have Linux, a legacy version of Eliza the Psychologist should still be in your copy of Emacs.

That said, you're doing the strawman thing again. I said protocols are important for treatment, but I'm pretty sure I never mentioned it in reference to diagnosis. Medical judgement's key for determining referrals for correct diagnosis in unclear situations. (Also, I remember reading that protocols are usually mandated by the state and/or insurance companies.)

You are an unnecessary middle man if all you do is follow protocols. Your argument for freedom of choice is self-serving, not a true appeal for freedom.

(1) I don't see it. People come to you for treatment. You're always, by definition, a middle man. You're still necessary thanks to our nations' laws.

(2) Strawman -- where did I say anything about "freedom of choice"?

 

[hurdlepup]

Re-read the post. 🙄

I'm not talking about situations where off-label applications are the only available treatments. It's why I mentioned birth control, migraines, and epilepsy -- three things with a wide variety of options. Even those of us outside of medicine know that.



So following good science isn't a good way to prevent unnecessary deaths? Doesn't that suggest that science is irrelevant? If so, then why see a physician at all? 😕

I'm not quite sure I understand your argument. I thought it was this: doctors should be able to limit NP and PAs because (a) they know more science and (b) science saves lives. Yet when I pointed out that doctors are losing respect with the public because of their willingness to use more expensive meds off-label when cheaper, safer, and more effective meds are available that have been explicitly approved for the purpose, you respond with personal attacks and some irrelevant remark about something I didn't address.

So I'm starting to suspect that your logic doesn't resemble our Earth logic.

Your tone suggest you have already made up your mind on this matter. Have you been to medical school? Because if not, honestly, I would probably have a more open mind on the way medicine is practiced. You are really coming from a very limited knowledge base--no offense intended, but hopefully you can realize this fact.

 

[ReineAshe]

Neither the government nor industry is infallible. I'm not claiming that mistakes will never happen, rather I'm saying that companies have a much stronger interest in ensuring they don't poison their customers then the government does as their very survival depends on keeping their customers happy and satisfied.

This was true -- way back when. The problem with multinational corporations is that it's impossible for people to connect their preferences to their purchases. Look at why the Nestlé boycott failed. IIRC (let me double check this first), women stopped buying baby forumla, but there was no way for them to know that they were supporting the company when they bought dog food or cosmetics because it was made through a wholly owned subsidiaries at the time.

Moreover, the only effective tool we had -- Class Actions (aka "Corporate Criminal Law That Counts") -- has been effectively decimated. 🙁

More later.

 

[ReineAshe]

I don't think it's fair to lump PAs with NPs/DNPs. The training PAs receive, in my opinion, is far superior to that of the nursing midlevels (more basic science training, more clinical hours, fewer "fluff" courses like nurse activism, health policy, business administration, etc). Yet, you don't see them pushing aggressively for equivalent scope of practice as physicians. The only reason NPs can practice independently in some states is because of their powerful nursing lobby, not due to their training.

I think this post's subtext captures what this is really about.

 

[countingdays]

It is very difficult to respond to you because it is very hard to follow what you are trying to say. Your free-association writing style makes me wonder if you a in the midst of a manic episode.

I could not care less about planned parenthood's policies. Case examples are the weakest form of evidence.

'Off-label' does not in any way imply misuse. You don't seem to understand what you are rambling on and on about.

Education is a good thing. Trying to minimize education is a bad thing. You can disagree because it benefits you financially, but it's dishonest. I'm stating my opinion that increasing the responsibilities of less well trained individuals and displacing doctors with NPs and PAs represents a negative trend toward mediocrity.

I don't have any problem with NPs and PAs personally and there are circumstances where they have a role to play, but the movement to replace physician medical care with lesser medical care on a massive scale is a move in the wrong direction. We should always be improving, not trying to get by with the bare minimum.

 

[countingdays]

d

 

[ReineAshe]

OK sweat pea, I'll play.

Ad homs. 🙄

...but at least now you're getting at something with merit -- it's not necessarily that you are ignorant or anything short of a genius; it's simply a case of you stepping beyond the confines of your knowledge. It happens. A lot. Hell, look at our President....

Ad hom. 🙄

(BTW, I'm currently in research/bioinformatics and my fiancé's a physician. I made sure to stick to what I know.)

Now how exactly does the below follow in your "Earth logic"???

For the record, this isn't my argument. It's a Prof. Palmer's (sp?).

From a health care policy perspective, med malpractive was effectively America's social safety net. From the average patient's perspective it is now, for all intents and purposes, gone. This is particularly true for drugs. So the more media covers the relationship between docs and Big Pharma, the worse physicians look, particularly for me-too drugs and certain off-label uses. By contrast, NPs and PAs are going to look rosy.

No sweet pea, not always -- nice straw man though. 😉

Strawman =/= taking his logic to its conclusion.

Sometimes the "science" is really not that good while at other times it simply does not exist. If cookie cutter algorithmic medicine were all that great you would only need a provider for the purpose of the technician...

Re-read my post. I'm taking the Atul Gawande position. I'm not talking about cases where the science may not be good or not exist. I'm talking about cases where it does exist and there's just no question, like aspirin in kids with fevers or Paxil in cases where patients tried to commit suicide on Prozac.

But let's face it: sometimes you only DO need a tech. And that's what NPs and PAs may be good for. You still need someone to make sure the patient doesn't need a referral.

I can see that. It's OK....

🙄 I can see someone who can't grasp sarcasm...

Cannot remember ever making any such argument....

Sorry; got you confused with G253. Stupid lack of icons on reply screen. My bad. 🙁

but, be that as it may, let's look at it all the same. Inherent in this assumption is that encyclopedic knowledge is all that is necessary or involved in clinical medicine; this is an assumption out of lack of experience and actual knowledge of the practice of medicine -- and a rather common one.

Actually, I'm not the one who's saying that more education is necessary to make a better practioner -- that's GypsySongman. I'm the first to admit I don't know.

I just know that the subtext and text in this thread don't match.

 

[ReineAshe]

It is very difficult to respond to you because it is very hard to follow what you are trying to say. Your free-association writing style makes me wonder if you a in the midst of a manic episode.

Ad hom. 🙄 Bored in suburban nowhere =/= manic episode. (But to be fair, I am watching something in Russian, so my English may be a bit more liquid-ey than normal.)

If you can't follow it with quotes, I don't know what to say.

I could not care less about planned parenthood's policies. Case examples are the weakest form of evidence.

So? The fundamental point's still true. Look it up on Wikipedia under Nurse Practitoner.

'Off-label' does not in any way imply misuse.

Then why are state boards and insurance companies so focused on protocols? Why do most state courts have different burden of proof standards for off-label use than FDA approved uses? It's because, legally, it implies misuse.

You don't seem to understand what you are rambling on and on about.

In my experience, people only resort to ad homs when they know they can no longer rely on logic nor evidence.

Education is a good thing. Trying to minimize education is a bad thing. You can disagree because it benefits you financially, but it's dishonest. I'm stating my opinion that increasing the responsibilities of less well trained individuals and displacing doctors with NPs and PAs represents a negative trend toward mediocrity.

Strawman much?

Who said anything about trying to minimize education? Who said anything about me being an NP or PA?