MD vs DNP: 20,000 hours makes a difference

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Completely agree, but the problem here is several-fold:

1) The people responsible for enacting scope-of-practice legislation have little to no understanding of clinician training

2) The same people do not have a sophisticated understanding of clinical literature or the complexities of healthcare quality and outcomes, thus when your local NP lobbying group approaches them with studies like this, they fall prey to the "outcomes are similar ergo quality is similar!" argument being made by these groups

3) Given the two points above, those "responsible" for funding healthcare systems (i.e., politicians) see midlevel providers as "equivalent" to physicians with a significant cost savings - what a deal!

The point that I'm getting it as that those who hold the keys to this issue don't care at all that there is almost certainly a difference in the quality of care provided by physicians vs. midlevel providers. This is especially true in my field (psychiatry), where the nuances of psychiatric management are completely lost on most physicians that actually had to rotate on a psychiatric service, much less NPs (even those trained with specifically with a psychiatric focus). I can't even count how many patients have been admitted that come in on bizarre medication regimens and management plans that make zero sense - though, in fairness, this also happens with bona fide psychiatrists as well. The problem with the studies often cited by NP groups as demonstrating "equivalence" is that I don't think that they're high enough resolution to detect differences - the major differences are in the difficult cases and in long-term outcomes IMO, which have not been sufficiently studied as far as I can tell.

As a resident, I have become more convinced of the substandard training that midlevels receive as I've gone through my training. I hate working with NPs. PAs tend to be more consistent in my mind but nonetheless often have huge deficiencies in their training (I had to explain to a PA what CIWA was on an inpatient service for one of their patients who was going through benzo withdrawal, just to give an example). These are things not captured when you randomize patients to NP-led vs. physician-led treatment teams and follow-up their mean HbA1c or SBP after 6 months. I can treat a monkey to manage someone's DM or HTN such that the results would likely be equivalent to a physician. Should we allow monkeys to practice medicine? Of course not.

This trend is creating a very real two-tiered healthcare system where those with limited resources are more often than not managed by midlevels because the systems responsible for providing super cheap care to large swaths of the population tend to hire midlevels as a cost-saving measure. Or, again, that at least seems to be the case in my local area. Patients often don't realize that they're being treated as a non-physician, and many times a patient had told me that they're being treated by Dr. X and I find out that "Dr. X" is actually an NP or PA. I'm impressed when patients are able to differentiate between the supervising physician at whatever practice they receive care and the fact that they see that physician's NP/PA instead. The very nature of the patient/clinician relationship involves a substantial knowledge gap which makes it difficult for "consumers" to understand the quality of the good they're "consuming." Just about the only thing I think they can reliably describe is how "good" they feel about the care they received - regardless of the quality of that care. Enter Press-Ganey and the laser focus on patient satisfaction scores.

Some midlevels are great - in those cases, I have absolutely no problem with them practicing essentially unsupervised because they are clearly competent and knowledgable. The problem in my view, though, is that these folks tend to be the exception rather than the rule. Of course, this is can also be a problem with physicians - many physicians are horrible physicians and have no business practicing medicine. I think the subtext by many of the midlevel groups is that this has been accepted as collateral damage and a hazard of providing medical care generally, ergo midlevels should be allowed to practice medicine because everyone mistakes. I don't find this convincing and think it's a shame that that's what's happening; if anything, I think this speaks to the importance of more rigorous selection of who gets to practice medicine and ensuring that those folks receive rigorous training, not a lowering of standards to match the "standard of care."

I don't think any physician will disagree with the author in the OP. To many of us, the distinction between midlevel and physician and the fruit born from the differences in training are obvious. The problem, though, is that those responsible for legally setting scope of practice often don't have this experience or level of understanding of the situation. Thus, while appreciated, this piece very much preaches to the choir.
 
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NickNaylor said:
Completely agree, but the problem here is several-fold:

1) The people responsible for enacting scope-of-practice legislation have little to no understanding of clinician training

2) The same people do not have a sophisticated understanding of clinical literature or the complexities of healthcare quality and outcomes, thus when your local NP lobbying group approaches them with studies like this, they fall prey to the "outcomes are similar ergo quality is similar!" argument being made by these groups
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There is also a separate problem in both the medical community and in politics/lawmaking: people don't understand statistics and conclusions that can be drawn from certain methods. The study you linked is a perfect example: "nonsigificant results" doesn't allow us to conclude that the outcomes are "equivalent" as noted in the conclusion of the paper. A basic understanding of statistics would allow us to see why that is not true, yet people fall prey to that fallacy all the time. The best anyone could say is that there was insufficient evidence of a difference, which is logically different from concluding equivalence.

NickNaylor said:
The problem with the studies often cited by NP groups as demonstrating "equivalence" is that I don't think that they're high enough resolution to detect differences - the major differences are in the difficult cases and in long-term outcomes IMO, which have not been sufficiently studied as far as I can tell.
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This just builds from my first point: if legislators, or at least people in the medical community, had a better understanding of statistics, the study showing "equivalence" wouldn't hold much weight because that conclusion does not and cannot follow from that paper. They wrote it and it was published because someone without adequate statistical training wasn't involved in the research and review process. Law makers trust "the science" that was used to arrive at the so-called conclusion of "equivalence" in this study. There are methods for testing equivalence, but this was not one of them, and studies like this are quite common.
 
NickNaylor said:
Completely agree, but the problem here is several-fold:

1) The people responsible for enacting scope-of-practice legislation have little to no understanding of clinician training

2) The same people do not have a sophisticated understanding of clinical literature or the complexities of healthcare quality and outcomes, thus when your local NP lobbying group approaches them with studies like this, they fall prey to the "outcomes are similar ergo quality is similar!" argument being made by these groups

3) Given the two points above, those "responsible" for funding healthcare systems (i.e., politicians) see midlevel providers as "equivalent" to physicians with a significant cost savings - what a deal!

The point that I'm getting it as that those who hold the keys to this issue don't care at all that there is almost certainly a difference in the quality of care provided by physicians vs. midlevel providers. This is especially true in my field (psychiatry), where the nuances of psychiatric management are completely lost on most physicians that actually had to rotate on a psychiatric service, much less NPs (even those trained with specifically with a psychiatric focus). I can't even count how many patients have been admitted that come in on bizarre medication regimens and management plans that make zero sense - though, in fairness, this also happens with bona fide psychiatrists as well. The problem with the studies often cited by NP groups as demonstrating "equivalence" is that I don't think that they're high enough resolution to detect differences - the major differences are in the difficult cases and in long-term outcomes IMO, which have not been sufficiently studied as far as I can tell.

As a resident, I have become more convinced of the substandard training that midlevels receive as I've gone through my training. I hate working with NPs. PAs tend to be more consistent in my mind but nonetheless often have huge deficiencies in their training (I had to explain to a PA what CIWA was on an inpatient service for one of their patients who was going through benzo withdrawal, just to give an example). These are things not captured when you randomize patients to NP-led vs. physician-led treatment teams and follow-up their mean HbA1c or SBP after 6 months. I can treat a monkey to manage someone's DM or HTN such that the results would likely be equivalent to a physician. Should we allow monkeys to practice medicine? Of course not.

This trend is creating a very real two-tiered healthcare system where those with limited resources are more often than not managed by midlevels because the systems responsible for providing super cheap care to large swaths of the population tend to hire midlevels as a cost-saving measure. Or, again, that at least seems to be the case in my local area. Patients often don't realize that they're being treated as a non-physician, and many times a patient had told me that they're being treated by Dr. X and I find out that "Dr. X" is actually an NP or PA. I'm impressed when patients are able to differentiate between the supervising physician at whatever practice they receive care and the fact that they see that physician's NP/PA instead. The very nature of the patient/clinician relationship involves a substantial knowledge gap which makes it difficult for "consumers" to understand the quality of the good they're "consuming." Just about the only thing I think they can reliably describe is how "good" they feel about the care they received - regardless of the quality of that care. Enter Press-Ganey and the laser focus on patient satisfaction scores.

Some midlevels are great - in those cases, I have absolutely no problem with them practicing essentially unsupervised because they are clearly competent and knowledgable. The problem in my view, though, is that these folks tend to be the exception rather than the rule. Of course, this is can also be a problem with physicians - many physicians are horrible physicians and have no business practicing medicine. I think the subtext by many of the midlevel groups is that this has been accepted as collateral damage and a hazard of providing medical care generally, ergo midlevels should be allowed to practice medicine because everyone mistakes. I don't find this convincing and think it's a shame that that's what's happening; if anything, I think this speaks to the importance of more rigorous selection of who gets to practice medicine and ensuring that those folks receive rigorous training, not a lowering of standards to match the "standard of care."

I don't think any physician will disagree with the author in the OP. To many of us, the distinction between midlevel and physician and the fruit born from the differences in training are obvious. The problem, though, is that those responsible for legally setting scope of practice often don't have this experience or level of understanding of the situation. Thus, while appreciated, this piece very much preaches to the choir.
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Are there better studies then the one you linked that shows a difference in outcomes ?
 
libertyyne said:
Are there better studies then the one you linked that shows a difference in outcomes ?
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Not that I've found. The last time I reviewed the literature on this topic (a couple of years ago) there were only about 20-30 studies with similar designs though most used, I would argue, more useless outcome measures (for example, mean SBP in patients with hypertension, mean HbA1c in patients with diabetes, etc.). Just about the only seemingly consistent and relatively rigorous finding in these studies is that midlevel-run services/care are cheaper than their physician counterparts. IIRC, this was true even when accounting for the cost of diagnostic testing and procedures, which is often a refrain cited by many as a "hidden cost" of midlevel-provided care.

There's actually a Cohrane review of this topic that is fairly recent and reviews all the literature at the time the review was published. If you're interested in reading more about this topic, I would suggest checking out that paper.
 
libertyyne said:
Are there better studies then the one you linked that shows a difference in outcomes ?
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NickNaylor said:
Not that I've found. The last time I reviewed the literature on this topic (a couple of years ago) there were only about 20-30 studies with similar designs though most used, I would argue, more useless outcome measures (for example, mean SBP in patients with hypertension, mean HbA1c in patients with diabetes, etc.). Just about the only seemingly consistent and relatively rigorous finding in these studies is that midlevel-run services/care are cheaper than their physician counterparts. IIRC, this was true even when accounting for the cost of diagnostic testing and procedures, which is often a refrain cited by many as a "hidden cost" of midlevel-provided care.

There's actually a Cohrane review of this topic that is fairly recent and reviews all the literature at the time the review was published. If you're interested in reading more about this topic, I would suggest checking out that paper.
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Iirc, there's an anesthesia article showing care team (resident or crna) > MD only > crna, but I haven't read the literature here in a good while

Edit: this may have been a cost effectiveness study? Trying to find it
 
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Papers like the one listed above make me feel like I'm on crazy pills. Like, why am I training for 4 years in medical school, 3 years of residency, and 2 years of critical care fellowship if someone with 2 or less years of training can treat the same critically ill patients with no problem? Why do we even have an f'ing standard? It's insulting to my life's work.

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sonofva said:
Papers like the one listed above make me feel like I'm on crazy pills. Like, why am I training for 4 years in medical school, 3 years of residency, and 2 years of critical care fellowship if someone with 2 or less years of training can treat the same critically ill patients with no problem? Why do we even have an f'ing standard? It's insulting to my life's work.

Sent from my SM-G930V using SDN mobile
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Agreed.
 
sonofva said:
Papers like the one listed above make me feel like I'm on crazy pills. Like, why am I training for 4 years in medical school, 3 years of residency, and 2 years of critical care fellowship if someone with 2 or less years of training can treat the same critically ill patients with no problem? Why do we even have an f'ing standard? It's insulting to my life's work.
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To play devil's advocate: why does it take 14 freaking years of post high school education to train a hand surgeon to perform carpal tunnel release and fracture reductions? Does the hand surgeon really hearken back to his 4 years of undergrad biology and 4 years of biochemistry and OB/GYN rotations in medical school when cutting into a hand, or does he mostly rely on Year 14 of his training, the hand fellowship? How much worse would that surgeon be if instead of spending 13 years in undergrad, med school, and general ortho, he instead spent 3 years after high school learning how and when to operate on the hand? This **** isn't rocket science.

Ever seen a youtube video of a colonoscopy/polyp excision? Yes, I know that's not all a gastroenterologist does, but it's by far the largest chunk. Do you really need to spend 14 years in school before you can stick a tube up someone's arse, spot what looks like a mushroom in his colon, and put a little noose around the stalk to snip it off?

It's just a matter of time before midlevels take over every single high volume procedure and the majority of office visits, because frankly there is no reason why they shouldn't. The only reason it hasn't happened sooner is that doctors used to own healthcare and nobody volunteers to be out of a job if he can help it. Now that healthcare is owned by corporate, the writing is on the wall. Corporate realizes that it can stop paying a GI doc 500k to put little lassos around anal mushrooms and pay midlevels 150k to do it instead, and that's the end of that.
 
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Brahnold Bloodaxe said:
To play devil's advocate: why does it take 14 freaking years of post high school education to train a hand surgeon to perform carpal tunnel release and fracture reductions? Does the hand surgeon really hearken back to his 4 years of undergrad biology and 4 years of biochemistry and OB/GYN rotations in medical school when cutting into a hand, or does he mostly rely on Year 14 of his training, the hand fellowship? How much worse would that surgeon be if instead of spending 13 years in undergrad, med school, and general ortho, he instead spent 3 years after high school learning how and when to operate on the hand? This **** isn't rocket science.

Ever seen a youtube video of a colonoscopy/polyp excision? Yes, I know that's not all a gastroenterologist does, but it's by far the largest chunk. Do you really need to spend 14 years in school before you can stick a tube up someone's arse, spot what looks like a mushroom in his colon, and put a little noose around the stalk to snip it off?

It's just a matter of time before midlevels take over every single high volume procedure and the majority of office visits, because frankly there is no reason why they shouldn't. The only reason it hasn't happened sooner is that doctors used to own healthcare and nobody volunteers to be out of a job if he can help it. Now that healthcare is owned by corporate, the writing is on the wall. Corporate realizes that it can stop paying a GI doc 500k to put little lassos around anal mushrooms and pay midlevels 150k to do it instead, and that's the end of that.
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I mean if patient outcomes are dependent on the long duration of training then they should become apparent when you study the matter. I am still waiting for a good study to show there is immense difference between outcomes of a midlevel vs a MD. The author of the original article highlights one incident with an NP, but that could have occured with an MD as well, that's why studies on this question matter. Everyone is quick to point out methodological flaws in the studies that do exist where they show no difference ,yet never present better studies where outcomes are superior for MDs. Do you really need 11 years to become a pediatrician? Perhaps 7 might suffice.
 
libertyyne said:
I mean if patient outcomes are dependent on the long duration of training then they should become apparent when you study the matter. I am still waiting for a good study to show there is immense difference between outcomes of a midlevel vs a MD. The author of the original article highlights one incident with an NP, but that could have occured with an MD as well, that's why studies on this question matter. Everyone is quick to point out methodological flaws in the studies that do exist where they show no difference ,yet never present better studies where outcomes are superior for MDs. Do you really need 11 years to become a pediatrician? Perhaps 7 might suffice.
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Because a study like that (looking at NPs with ZERO physician back-up in critically ill settings) would never get approved past an IRB. That's why the "nursing" studies all had physician support (especially for the critically ill patient study) if/when **** hits the fan, cause otherwise it's actively detrimental to patient care for a physician to say: "Well this is on study, and I can't help you with this, independent NP, b/c it's on study" and then the patient has a bad outcome.

If somebody has the pubmed link for that critically ill patients study though, I'd like to re-review it, but I'm not tarnishing my google or pubmed search history looking for garbage like that.

I don't care about the outpatient studies showing HTN and HbA1c medians are equal between NPs and physicians.
 
evilbooyaa said:
Because a study like that (looking at NPs with ZERO physician back-up in critically ill settings) would never get approved past an IRB. That's why the "nursing" studies all had physician support (especially for the critically ill patient study) if/when **** hits the fan, cause otherwise it's actively detrimental to patient care for a physician to say: "Well this is on study, and I can't help you with this, independent NP, b/c it's on study" and then the patient has a bad outcome.

If somebody has the pubmed link for that critically ill patients study though, I'd like to re-review it, but I'm not tarnishing my google or pubmed search history looking for garbage like that.

I don't care about the outpatient studies showing HTN and HbA1c medians are equal between NPs and physicians.
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you could totally set that as a outcome, number of times MD was contacted. I am pretty confident you could run the study you are talking about in rural icu's or emergency departments.
 
libertyyne said:
I mean if patient outcomes are dependent on the long duration of training then they should become apparent when you study the matter. I am still waiting for a good study to show there is immense difference between outcomes of a midlevel vs a MD. The author of the original article highlights one incident with an NP, but that could have occured with an MD as well, that's why studies on this question matter. Everyone is quick to point out methodological flaws in the studies that do exist where they show no difference ,yet never present better studies where outcomes are superior for MDs. Do you really need 11 years to become a pediatrician? Perhaps 7 might suffice.
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You try submitting an study proposal where patients will be randomized to an attending-run ICU or NP-only ICU, where NPs cannot consult intensivists. Or likewise with the same rules in any outpatient setting. See if there's an IRB that approves it.

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Lev0phed said:
You try submitting an study proposal where patients will be randomized to an attending-run ICU or NP-only ICU, where NPs cannot consult intensivists. Or likewise with the same rules in any outpatient setting. See if there's an IRB the approves it.

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If there is an actual chance that legislation would pass allowing them to practice without oversight I am pretty confident a IRB wouldn't have qualms with it.
 
libertyyne said:
I'm unsure why you are thinking an IRB wouldn't allow it.
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Because the people who run IRBs includes physicians and others who know things that may put patients at risk and aren't trying to find ways to cut down costs for society.

Seriously, it's been suggested before. I advocate that when you get to MS3, you try it and report back.
 
evilbooyaa said:
Because the people who run IRBs includes physicians and others who know things that may put patients at risk and aren't trying to find ways to cut down costs for society.

Seriously, it's been suggested before. I advocate that when you get to MS3, you try it and report back.
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I've passed studies through IRBs before. Ive been on an irb. Everyone wants to claim superiority in outcomes in this thread yet no one has the evidence to back it up. And if we frankly can't back it up with evidence perhaps it's time to look inwards and see if the extensive training is necessary.

Would you blame society of they opted for the cheaper option when no difference in outcomes is apparent?
 
This is America. Money talks. NPs are here to stay and will likely gain more autonomy in the future.
 
libertyyne said:
I've passed studies through IRBs before. Ive been on an irb. Everyone wants to claim superiority in outcomes in this thread yet no one has the evidence to back it up.
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The trials that would be required to produce such evidence cannot be ethically performed. As I told you already, there are no ICUs in this country where NPs are solely managing complex patients without any oversight from board certified intensevists. That is regardless of whether or not they can practice "independently" by the laws of the state they practice in. No hospital or insurance carrier allows such a thing to happen. And you cannot randomize sick patients to non-physician only care.

I agree that if trials are performed which exclude mid-levels from consulting physicians and they find no mortality benefit for physician-led care that medical schools need to be shut down across the country and everyone needs to be funneled into online nurse practitioner programs or PA schools. I don't think such trials will be done anytime soon, but who knows.

I do not accept that nursing lobby-sponsored and published retrospective cohort studies looking at ambulatory blood pressure readings or HBa1c constitutes anything even remotely close to solid evidence that NPs provide better or similar quality care.
 
libertyyne said:
I've passed studies through IRBs before. Ive been on an irb. Everyone wants to claim superiority in outcomes in this thread yet no one has the evidence to back it up. And if we frankly can't back it up with evidence perhaps it's time to look inwards and see if the extensive training is necessary.

Would you blame society of they opted for the cheaper option when no difference in outcomes is apparent?
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Then you formulate the study and pass it through an IRB.

Lev0phed said:
The trials that would be required to produce such evidence cannot be ethically performed. As I told you already, there are no ICUs in this country where NPs are solely managing complex patients without any oversight from board certified intensevists. That is regardless of whether or not they can practice "independently" by the laws of the state they practice in. No hospital or insurance carrier allows such a thing to happen. And you cannot randomize sick patients to non-physician only care.

I agree that if trials are performed which exclude mid-levels from consulting physicians and they find no mortality benefit for physician-led care that medical schools need to be shut down across the country and everyone needs to be funneled into online nurse practitioner programs or PA schools. I don't think such trials will be done anytime soon, but who knows.

I do not accept that nursing lobby-sponsored and published retrospective cohort studies looking at ambulatory blood pressure readings or HBa1c constitutes anything even remotely close to solid evidence that NPs provide better or similar quality care.
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Fully agree. Bolded portions are for emphasis.
 
libertyyne said:
Everyone is quick to point out methodological flaws in the studies that do exist where they show no difference ,yet never present better studies where outcomes are superior for MDs.
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I'm not sure if your post was directed towards the kind of comment I made, but I'll assume it was, for the sake of discussion. My very point is that the linked study, and others like it, do not show no difference despite the nonsignificant tests. This isn't a methodological flaw, necessarily, but it is a conclusion that can't be drawn from the methods employed. It's similar to saying that you know the patient's heart rate from drawing blood. The method does not convey that information and anyone claiming that it does is mistaken.

I don't have a study showing physician outcomes are superior, but is worth noting that the posted study that claims "no difference" or "equivalence" is mistaken in it's conclusion and it doesn't give support to the idea that no difference exists (to say it does uses a common and incorrect train of thought that is frequently used by those without a decent understanding of the stats used). The best information that study can provide is that we don't have enough evidence to conclude a difference exists. Again, this is logically different from saying there is equivalence.
 
Lev0phed said:
The trails that would be required to produce such evidence cannot be ethically performed. As I told you already, there are no ICUs in this country where NPs are solely managing complex patients without any oversight from board certified intensevists. That is regardless of whether or not they can practice "independently" by the laws of the state they practice in. No hospital or insurance carrier allows such a thing to happen. And you cannot randomize sick patients to non-physician only care.

I agree that if trials are performed which exclude mid-levels from consulting physicians and they find no mortality benefit for physician-led care that medical schools need to be shut down across the country and everyone needs to be funneled into online nurse practitioner programs or PA schools. I don't think such trials will be done anytime soon, but who knows.

I do not accept that nursing lobby-sponsored and published retrospective cohort studies looking at ambulatory blood pressure readings or HBa1c constitutes anything even remotely close to solid evidence that NPs provide better or similar quality care.
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I know of a few critical access hospitals in my area where critical care units are staffed with NPs and family practice docs. These are **** tier hospitals and send trainwrecks as transfers to the larger referral centers. I can pm you the names .
 
libertyyne said:
I know of a few critical access hospitals in my area where critical care units are staffed with NPs and family practice docs. These are **** tier hospitals and send trainwrecks as transfers to the larger referral centers. I can pm you the names .
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You do know that stabilizing a patient for transfer to a tertiary referral center is not the same as managing them from admission to discharge in an ICU setting, right?
 
dempty said:
I'm not sure if your post was directed towards the kind of comment I made, but I'll assume it was, for the sake of discussion. My very point is that the linked study, and others like it, do not show no difference despite the nonsignificant tests. This isn't a methodological flaw, necessarily, but it is a conclusion that can't be drawn from the methods employed. It's similar to saying that you know the patient's heart rate from drawing blood. The method does not convey that information and anyone claiming that it does is mistaken.

I don't have a study showing physician outcomes are superior, but is worth noting that the posted study that claims "no difference" or "equivalence" is mistaken in it's conclusion and it doesn't give support to the idea that no difference exists (to say it does uses a common and incorrect train of thought that is frequently used by those without a decent understanding of the stats used). The best information that study can provide is that we don't have enough evidence to conclude a difference exists. Again, this is logically different from saying there is equivalence.
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That's the thing though, if the outcomes are so different and the effect size is large, the amount of evidence required to display an effect would be miniscule. There are other issues with that as study as well, one NP was used in the entire study, the head to head comparison was between that NP and the fellows. Obviously it wasn't randomised or blinded.
Lev0phed said:
You do know that stabilizing a patient for transfer to a tertiary referral center is not the same as managing them from admission to discharge in an ICU setting, right?
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these hospitals keep patients in their critical care as well.
 
libertyyne said:
these hospitals keep patients in their critical care as well.
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Let me repost what I said, since you didn't seem to read it:

"You do know that stabilizing a patient for transfer to a tertiary referral center is not the same as managing them from admission to discharge in an ICU setting, right?"
 
evilbooyaa said:
Then you formulate the study and pass it through an IRB.



Fully agree. Bolded portions are for emphasis.
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I'm not the one making superiority claims. Plus that research is of little value to my residency application , coupled with the funding /years it would take to do something like that it is outside of my scope to perform at that point in my career.
 
libertyyne said:
That's the thing though, if the outcomes are so different and the effect size is large, the amount of evidence required to display an effect would be miniscule. There are other issues with that as study as well, one NP was used in the entire study, the head to head comparison was between that NP and the fellows. Obviously it wasn't randomised or blinded.
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I agree with regards to randomization and other issues. As mentioned prior, I think ethics come into play when trying to design a good study for this.

However, the "if the effect size were so big we would see it, but we don't so the care is equal..."-style argument doesn't work. It doesn't negate the issue that the methods, both logically and mathematically, do not allow for the conclusion that the outcomes are "equivalent" on the basis of a nonsignificant statistical test.
 
libertyyne said:
I know of a few critical access hospitals in my area where critical care units are staffed with NPs and family practice docs. These are **** tier hospitals and send trainwrecks as transfers to the larger referral centers. I can pm you the names .
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Are we now saying that FP docs are on the same level as NPs? Keep the discussion at the same level. Yes they may not have an intensivist, but there is probably some way to discuss a case with an ICU doctor. The study that you are proposing would have to completely eliminate that lifeline, which is unethical and will put patients in undue harm's way.
 
Lev0phed said:
Let me repost what I said, since you didn't seem to read it:

"You do know that stabilizing a patient for transfer to a tertiary referral center is not the same as managing them from admission to discharge in an ICU setting, right?"
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> Patient meets ICU criteria.
> Patient is admitted to ICU.
> Patient is managed by ICU team.
> Patient is discharged via death or back to the med surgery floor in the same hospital.
 
libertyyne said:
> Patient meets ICU criteria.
> Patient is admitted to ICU.
> Patient is managed by ICU team.
> Patient is discharged via death or back to the med surgery floor in the same hospital.
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You just got through telling me that these facilities transfer out most critically ill patients, hence these NPs you speak about are not leading the "ICU team" (in fact, in your example, they aren't even part of the ICU team).
 
libertyyne said:
I'm not the one making superiority claims. Plus that research is of little value to my residency application , coupled with the funding /years it would take to do something like that it is outside of my scope to perform at that point in my career.
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Why didn't you go to PA school if you thought you'd get equivalent training and be equally prepared to do whatever you want in medicine? It's not too late to turn around, since you haven't even started school yet.
 
Lev0phed said:
Why didn't you go to PA school if you thought you'd get equivalent training and be equally prepared to do whatever you want in medicine? It's not too late to turn around, since you haven't even started school yet.
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Thanks for dropping to the level of personal attacks. That's really conducive to the discussion. To answer your question : Id like to keep the option of cutting people open. Plus I don't think the education is equivalent, but what I think or don't think doesn't matter.evidence and Patient outcomes do.
 
libertyyne said:
Thanks for dropping to the level of personal attacks. That's really conducive to the discussion. To answer your question : Id like to keep the option of cutting people open. Plus I don't think the education is equivalent, but what I think or don't think doesn't matter.evidence and Patient outcomes do.
Click to expand...
What personal attack?

NPs will probably be doing surgery in a few years. If you think NPs can produce similar outcomes as intensevists with 6 years of training, surely they can produce similar surgical outcomes as general surgeons with 5.

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Lev0phed said:
What personal attack?

NPs will probably be doing surgery in a few years. If you think NPs can produce similar outcomes as intensevists with 6 years of training, surely they can produce similar surgical outcomes as general surgeons with 5.

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Click to expand...
I don't think that. But there is no evidence that disproves that either.
 
libertyyne said:
I don't think that. But there is no evidence that disproves that either.
Click to expand...
Theres no evidence that my three year old cant produce similar outcomes in managing diabetes either. He has a plastic stethoscope and knows how to write his name on a piece of paper. Why can't he practice medicine?

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As someone who has worked as an incompletely trained physician, my question is why they want so much independence? I worked as a flight doc after doing a transitional year internship in the Army. I didn't see many ICU level patients, I did have to independently take care of some folks who were pretty jacked up. It was terrifying. I knew what could go wrong, and I knew what the limits of my training were and that there were a lot of things I hadnt seen yet in training. It blows my mind that people with EVEN LESS TRAINING than I had at that point would want MORE RESPONSIBILITY and sicker patients. Where are these people's heads at?

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Lev0phed said:
Theres no evidence that my three year old cant produce similar outcomes in managing diabetes either. He has a plastic stethoscope and knows how to write his name on a piece of paper. Why can't he practice medicine?

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Click to expand...
I'm sure the NPs and payors will be swayed by that argument.

I didn't know three year olds had licenses to practice medicine.
 
libertyyne said:
I'm sure the NPs and payors will be swayed by that argument.

I didn't know three year olds had licenses to practice medicine.
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upload_2017-6-9_19-53-44.jpeg
 
Brahnold Bloodaxe said:
To play devil's advocate: why does it take 14 freaking years of post high school education to train a hand surgeon to perform carpal tunnel release and fracture reductions? Does the hand surgeon really hearken back to his 4 years of undergrad biology and 4 years of biochemistry and OB/GYN rotations in medical school when cutting into a hand, or does he mostly rely on Year 14 of his training, the hand fellowship? How much worse would that surgeon be if instead of spending 13 years in undergrad, med school, and general ortho, he instead spent 3 years after high school learning how and when to operate on the hand? This **** isn't rocket science.

Ever seen a youtube video of a colonoscopy/polyp excision? Yes, I know that's not all a gastroenterologist does, but it's by far the largest chunk. Do you really need to spend 14 years in school before you can stick a tube up someone's arse, spot what looks like a mushroom in his colon, and put a little noose around the stalk to snip it off?

It's just a matter of time before midlevels take over every single high volume procedure and the majority of office visits, because frankly there is no reason why they shouldn't. The only reason it hasn't happened sooner is that doctors used to own healthcare and nobody volunteers to be out of a job if he can help it. Now that healthcare is owned by corporate, the writing is on the wall. Corporate realizes that it can stop paying a GI doc 500k to put little lassos around anal mushrooms and pay midlevels 150k to do it instead, and that's the end of that.
Click to expand...

You need bread and butter cases to pay bills and keep your sanity. You can't be stuck doing hard stuff all the time. Then your pateints with their polytrauma injuries with your distal femur intra articular fractures will look at the NP who did a scope on a weekend warrior's knee and say, "I should have gone to an NP!" because their outcomes will be so different, but laypeople don't appreciate why; they only think it's because the NP is so super nice! (Break it down: the fracture guy is screwed no matter what you do or how well you do it, and will inherently have poorer outcomes than the casual tennis player because, after all, the first guy got hit by a car). Then you will be screwed. Then the NPs who only did knee scopes will say, "Oh, slapping a plate on a distal femur isn't too hard. I'll just go practice with some stuff from Home Depot" and then what?
No. Just no. You went to school for two years online after undergrad? Cool. You don't get to cut. Go get my gloves.
 
sonofva said:
As someone who has worked as an incompletely trained physician, my question is why they want so much independence? I worked as a flight doc after doing a transitional year internship in the Army. I didn't see many ICU level patients, I did have to independently take care of some folks who were pretty jacked up. It was terrifying. I knew what could go wrong, and I knew what the limits of my training were and that there were a lot of things I hadnt seen yet in training. It blows my mind that people with EVEN LESS TRAINING than I had at that point would want MORE RESPONSIBILITY and sicker patients. Where are these people's heads at?

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Click to expand...

Grandma-with-money.jpg
 
NickNaylor said:
Completely agree, but the problem here is several-fold:

1) The people responsible for enacting scope-of-practice legislation have little to no understanding of clinician training

2) The same people do not have a sophisticated understanding of clinical literature or the complexities of healthcare quality and outcomes, thus when your local NP lobbying group approaches them with studies like this, they fall prey to the "outcomes are similar ergo quality is similar!" argument being made by these groups

3) Given the two points above, those "responsible" for funding healthcare systems (i.e., politicians) see midlevel providers as "equivalent" to physicians with a significant cost savings - what a deal!

The point that I'm getting it as that those who hold the keys to this issue don't care at all that there is almost certainly a difference in the quality of care provided by physicians vs. midlevel providers. This is especially true in my field (psychiatry), where the nuances of psychiatric management are completely lost on most physicians that actually had to rotate on a psychiatric service, much less NPs (even those trained with specifically with a psychiatric focus). I can't even count how many patients have been admitted that come in on bizarre medication regimens and management plans that make zero sense - though, in fairness, this also happens with bona fide psychiatrists as well. The problem with the studies often cited by NP groups as demonstrating "equivalence" is that I don't think that they're high enough resolution to detect differences - the major differences are in the difficult cases and in long-term outcomes IMO, which have not been sufficiently studied as far as I can tell.

As a resident, I have become more convinced of the substandard training that midlevels receive as I've gone through my training. I hate working with NPs. PAs tend to be more consistent in my mind but nonetheless often have huge deficiencies in their training (I had to explain to a PA what CIWA was on an inpatient service for one of their patients who was going through benzo withdrawal, just to give an example). These are things not captured when you randomize patients to NP-led vs. physician-led treatment teams and follow-up their mean HbA1c or SBP after 6 months. I can treat a monkey to manage someone's DM or HTN such that the results would likely be equivalent to a physician. Should we allow monkeys to practice medicine? Of course not.

This trend is creating a very real two-tiered healthcare system where those with limited resources are more often than not managed by midlevels because the systems responsible for providing super cheap care to large swaths of the population tend to hire midlevels as a cost-saving measure. Or, again, that at least seems to be the case in my local area. Patients often don't realize that they're being treated as a non-physician, and many times a patient had told me that they're being treated by Dr. X and I find out that "Dr. X" is actually an NP or PA. I'm impressed when patients are able to differentiate between the supervising physician at whatever practice they receive care and the fact that they see that physician's NP/PA instead. The very nature of the patient/clinician relationship involves a substantial knowledge gap which makes it difficult for "consumers" to understand the quality of the good they're "consuming." Just about the only thing I think they can reliably describe is how "good" they feel about the care they received - regardless of the quality of that care. Enter Press-Ganey and the laser focus on patient satisfaction scores.

Some midlevels are great - in those cases, I have absolutely no problem with them practicing essentially unsupervised because they are clearly competent and knowledgable. The problem in my view, though, is that these folks tend to be the exception rather than the rule. Of course, this is can also be a problem with physicians - many physicians are horrible physicians and have no business practicing medicine. I think the subtext by many of the midlevel groups is that this has been accepted as collateral damage and a hazard of providing medical care generally, ergo midlevels should be allowed to practice medicine because everyone mistakes. I don't find this convincing and think it's a shame that that's what's happening; if anything, I think this speaks to the importance of more rigorous selection of who gets to practice medicine and ensuring that those folks receive rigorous training, not a lowering of standards to match the "standard of care."

I don't think any physician will disagree with the author in the OP. To many of us, the distinction between midlevel and physician and the fruit born from the differences in training are obvious. The problem, though, is that those responsible for legally setting scope of practice often don't have this experience or level of understanding of the situation. Thus, while appreciated, this piece very much preaches to the choir.
Click to expand...
Patient satisfaction linked to higher health-care expenses and mortality

The most amusing part is, the more patients like their care, the more likely it is to kill them.
 
Mad Jack said:
Patient satisfaction linked to higher health-care expenses and mortality

The most amusing part is, the more patients like their care, the more likely it is to kill them.
Click to expand...

Of course it does. You see this all the time with "VIP" patients. At our university hospital, "VIP" patients almost always result in problems; standard processes are changed which can result in substandard care, the expectation of "VIP" care adds a burden on the physicians and the staff, etc. I detest the concept of VIP care on its face, but even beyond that it has tangible impacts on care in a negative way.

This problem is somewhat different but ultimately related to the same issue: patients' perceived quality of care they receive has very little relation the actual quality of care provided. There are some things patients notice which I think do have some relation to quality - e.g., time spent talking with them, feeling like they're being listened to, responsive to complaints, etc. - but patients are ultimately the worst judges of what actually matters when treating patients: the actual medical care.
 
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