Nurse practitioners are better than MDs

Burrell College of Osteopathic Medicine
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IknowImnotadoctor said:
Nothing I could ever post could overcome your confirmation bias, I've tried.
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johnnydrama said:
I thought you were a libertarian? Shouldn’t you be against licensure? Shouldn’t these individuals be allowed to practice freely as long as they don’t misrepresent their credentials?

If physicians are better than NPs, PAs, and uncredentialed weirdos peddling crystals, shouldn’t that be decided in the marketplace?

Quotes from Friedman’s “Capitalism and Freedom”:



He has no objections to certifications or laws against misrepresentation.

Please note I am not advocating his arguments (although I do see some merit in them), but your rather diehard libertarian positions elsewhere make this position somewhat of an outlier.

Following video clip, not just about medical licensure (first minute against FDA drug approval, last minutes about negative income tax). I am not advocating Friedman’s positions, but I do find them well reasoned and interesting, even if I do not agree with the solutions he proposes:

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Free market doesn't work in this case. Your typical patient will see an NP in a white coat and assume they're a doctor. Don't believe? Read some NP reviews where people call them "physicians."
 
IknowImnotadoctor said:
If the physician lobby was worried about patient safety they would be fighting the naturopathic “physicians” tooth and nail. The lobby is worried about money not people, because treating and educating patients who would rather go to a naturopath would take time and effort. They would prefer that the patients who use turmeric to treat cancer stay out of their waiting rooms. Don’t give me the “patient safety” argument. It’s disengenious and everyone out of medical school knows it.
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We tried that with Chiropractors and lost. Now we welcome them. :shudder:

If I could flip a switch and give all NPs full medical practice rights and jettison all chiropractors into outer space, I would do it.
 
johnnydrama said:
I thought you were a libertarian? Shouldn’t you be against licensure? Shouldn’t these individuals be allowed to practice freely as long as they don’t misrepresent their credentials?

If physicians are better than NPs, PAs, and uncredentialed weirdos peddling crystals, shouldn’t that be decided in the marketplace?

Quotes from Friedman’s “Capitalism and Freedom”:



He has no objections to certifications or laws against misrepresentation.

Please note I am not advocating his arguments (although I do see some merit in them), but your rather diehard libertarian positions elsewhere make this position somewhat of an outlier.

Following video clip, not just about medical licensure (first minute against FDA drug approval, last minutes about negative income tax). I am not advocating Friedman’s positions, but I do find them well reasoned and interesting, even if I do not agree with the solutions he proposes:

Click to expand...

I’m all for a buyer beware free for all. Pay the pizza guy to take out your appendix? Fine by me........if govt steps out altogether

It’s not ok however for the govt to lie to people by pretending physicians and midlevels are equivalent and interchangeable
 
MedicineZ0Z said:
Free market doesn't work in this case. Your typical patient will see an NP in a white coat and assume they're a doctor. Don't believe? Read some NP reviews where people call them "physicians."
Click to expand...

Those people should just die if they don't know a NP from an MD, right? Free market?
 
MedicineZ0Z said:
Free market doesn't work in this case. Your typical patient will see an NP in a white coat and assume they're a doctor. Don't believe? Read some NP reviews where people call them "physicians."
Click to expand...

I am not advocating Friedman’s positions, but if @sb247 is being honest with his other stated beliefs he should.

Licensure is somewhat protectionist, and I don’t think that MDs and NPs receive equal training.

I would like to see greater regulation of MD, DO, and NP programs, particularly the rash of new DO schools that seem to be more of a money grab than legitimate education. And NP education is the Wild West and needs to be much better regulated.
 
sb247 said:
I’m all for a buyer beware free for all. Pay the pizza guy to take out your appendix? Fine by me........if govt steps out altogether

It’s not ok however for the govt to lie to people by pretending physicians and midlevels are equivalent and interchangeable
Click to expand...

Then why are you even arguing on these boards at all if the free market should determine the outcomes anyway?
 
sb247 said:
I’m all for a buyer beware free for all. Pay the pizza guy to take out your appendix? Fine by me........if govt steps out altogether

It’s not ok however for the govt to lie to people by pretending physicians and midlevels are equivalent and interchangeable
Click to expand...

They don’t. If a NP calls herself an MD, she can be sued and imprisoned.

The phrase “doctor” we lost a long time ago in a lawsuit against the spine quacks.
 
IknowImnotadoctor said:
If you're going to comment, you may want to read the article first.
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What does that article say? It's not about treatment folks. It's about who has the better ability to diagnose when presented with complex cases. Any finishing 3rd year med student can treat anything once they know the diagnoses.
 
IknowImnotadoctor said:
I'll try though. Here's an article by an MD.

Process and Outcome Measures among COPD Patients with a Hospitalization Cared for by an Advance Practice Provider or Primary Care Physician

Do what you do; ignore the outcomes, focus on the limitations, and then tell me this study doesn't prove a thing because it's not absolutely perfect (even though no study is) ...
Click to expand...
I read through it pretty quick......can you tell me how many of the midlevel's patients were seen by a supervised midlevel and how many were seen by an independent?
 
W19 said:
What does that article say? It's not about treatment folks. It's about who has the better ability to diagnose when presented with complex cases. Any finishing 3rd year med student can treat anything once they know the diagnoses.
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Great opinion, feel free to prove it.
 
The article splits treatment groups into younger healthier less co-morbid people vs older sicker people. What conclusion should we draw? That the NP group didn't harm the younger healthier subgroup? That the younger people, healther by study design, need an ED visit less?

What I'm curious about is what conclusions YOU are drawing from this.
 
johnnydrama said:
I am not advocating Friedman’s positions, but if @sb247 is being honest with his other stated beliefs he should.

Licensure is somewhat protectionist, and I don’t think that MDs and NPs receive equal training.

I would like to see greater regulation of MD, DO, and NP programs, particularly the rash of new DO schools that seem to be more of a money grab than legitimate education. And NP education is the Wild West and needs to be much better regulated.
Click to expand...

johnnydrama said:
They don’t. If a NP calls herself an MD, she can be sued and imprisoned.

The phrase “doctor” we lost a long time ago in a lawsuit against the spine quacks.
Click to expand...
I'm all for a free for all.......just not for the govt pitching to people that physicians are somehow equivalent with NPs
 
MedicineZ0Z said:
His page is largely people in medicine or premeds along with RNs (who dislike NPs) + PAs (who also dislike NPs). Her comment on her own public page seemed to get nothing but love. So while a (growing) minority - important to proceed cautiously as a profession. This "be collaborative" and nice guy thing backfires hard.
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Meh, she deleted it on her Twitter and her passive aggressiveness on its ability to incite passion among readers is being met with a slew of only negative replies. I haven't seen a positive one yet. The only positive ones I've seen were on that zdoggmd post.
 
sb247 said:
I read through it pretty quick......can you tell me how many of the midlevel's patients were seen by a supervised midlevel and how many were seen by an independent?
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I sure hope you know what a joke "supervision" and "collaborative agreements" are in the overwhelming majority of cases. But there you go, confirmation bias at its finest. Well done.
 
sb247 said:
I'm all for a free for all.......just not for the govt pitching to people that physicians are somehow equivalent with NPs
Click to expand...

Where is the government “pitching” that?

They can both receive reimbursement from CMS (so can the chiropractors), aside from that have seen no promotion of NPs over MDs, and if patients really care they can refuse to see an NP, it just might take a lot longer.

Btw, did you refuse GME funding during residency and are you going to refuse all government money during practice?

Medicine has great job security because we are heavily subsidized by the government and have high barriers to entry. It’s a funny place for a libertarian, although you’re certainly not alone, but have to be pretty blind to your own hypocrisy.

A large part of medical practice really doesn’t require medical education, so in the end this debate all comes down to our value in the market of supply and demand. I’m happy to benefit from this, but don’t think there’s much of an argument for it on its merits.
 
True that experience accounts for a lot of what we do in medicine... in fact, in any profession. There is however, a problem with NP's... they are not taking USMLE's. I believe that since they want to be like MD's, they should take USMLE as well. Once again, I am not saying that there should not be NP's but, they should be held to a higher level of accountability if their responsibility is much higher than that of a regular nurse.

It is so much easier to become a nurse and subsequently a NP. Midlevel practitioners of course, are still learning but, like I said before, that applies to any field or profession. Not everything is taught in medical school... there is no time. Too much information and not enough time. Most of what you learn, a lot of what you learn is self-taught.

Let me clarify, I am not saying that there should not be NP's or saying anything bad about them. Just saying that the rules are NOT fair to MD's and life is too easy for NP.
 
johnnydrama said:
Where is the government “pitching” that?

They can both receive reimbursement from CMS (so can the chiropractors), aside from that have seen no promotion of NPs over MDs, and if patients really care they can refuse to see an NP, it just might take a lot longer.

Btw, did you refuse GME funding during residency and are you going to refuse all government money during practice?

Medicine has great job security because we are heavily subsidized by the government and have high barriers to entry. It’s a funny place for a libertarian, although you’re certainly not alone, but have to be pretty blind to your own hypocrisy.

A large part of medical practice really doesn’t require medical education, so in the end this debate all comes down to our value in the market of supply and demand. I’m happy to benefit from this, but don’t think there’s much of an argument for it on its merits.
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I don't think the govt should be involved in residency funding. I would gladly vote against it. But govt currently has the monopoly power so I have to deal with it as it is until it changes.....
 
IknowImnotadoctor said:
I'll try though. Here's an article by an MD.

Process and Outcome Measures among COPD Patients with a Hospitalization Cared for by an Advance Practice Provider or Primary Care Physician

Do what you do; ignore the outcomes, focus on the limitations, and then tell me this study doesn't prove a thing because it's not absolutely perfect (even though no study is) ...
Click to expand...

It actually doesn't. Obviously no study is "absolutely perfect" but until they start doing well designed studies looking at actual hard clinical endpoints then the argument here stands.

Even in this study you linked to they mention that, "The more frequent specialist consults with NP care may be due to the recognized need for expertise and skills outside of the NP’s scope of practice for complex patients." They also state that they were not able to distinguish those cared solely by APPs acting independently vs those acting under physician supervision. COPD severity also was not measured. So it shows that 30 day readmission was the same (a soft endpoint in study populations that were likely not equal) and that the APPs here were good at algorithmic care with use of beta-agonists, oxygen, etc....

I work with plenty of NPs and PAs and the vast majority know what they are good at as well as their limitations. I think the problem some of us have is when there's disingenuous effort to to push more independent NP care in the name of allowing more primary care for the underserved when I don't see them flocking to rural underserved primary care but higher paying specialities. I think it's also disingenuous for them to equate NP's education and knowledge base to that of a physician's in the same field.
 
irJanus said:
The article splits treatment groups into younger healthier less co-morbid people vs older sicker people. What conclusion should we draw? That the NP group didn't harm the younger healthier subgroup? That the younger people, healther by study design, need an ED visit less?

What I'm curious about is what conclusions YOU are drawing from this.
Click to expand...

The NP group had a higher chance of being rural, were more often male and were more likely Medicaid patients with lower SES. All of these factors significantly increased their risk. The groups weren't "split" the study was simply describing the patient panel, nor did they say how significant the differences were. Find me a perfect study, and a unicorn and an honest politician while you're at it. Even better, find me a study that supports your position.
 
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johnnydrama said:
Where is the government “pitching” that?

They can both receive reimbursement from CMS (so can the chiropractors), aside from that have seen no promotion of NPs over MDs, and if patients really care they can refuse to see an NP, it just might take a lot longer.
.
Click to expand...
When the govt takes on the moral hazard of deciding who is good enough to be a medical decision maker for the "non trained" masses, they do so under the premise that others don't have to think about who their medical professional is because the govt does the screening for them. That's why they need to be all in or all out. Prior to midlevel independence it was "the medical professionals you can trust are these doctors" then with legislative changes it became "oh yeah, and also these NPs are just as good, trust us"

And the govt it wrong
 
drdeliz said:
True that experience accounts for a lot of what we do in medicine... in fact, in any profession. There is however, a problem with NP's... they are not taking USMLE's. I believe that since they want to be like MD's, they should take USMLE as well. Once again, I am not saying that there should not be NP's but, they should be held to a higher level of accountability if their responsibility is much higher than that of a regular nurse.
Click to expand...

How is the USMLE about accountability?

I’m sure any reasonable* multiple choice taker with a few months of review time and access to UWorld could pass it, no MD required.

*My definition of reasonable here is probably not mainstream.
 
sb247 said:
I don't think the govt should be involved in residency funding. I would gladly vote against it. But govt currently has the monopoly power so I have to deal with it as it is until it changes.....
Click to expand...

Pretty sure there are unaccredited residencies you could choose from without funding. Just look at the types of things available to FMGs outside the match.

And you could refuse to receive your part of that government money, I’m sure the hospital would be happy to keep it.

Live your ideals. No one is forcing you to take government money.

Residencies before GME funding often charged for the privilege of training you, don’t you want to go back to those days free from government intervention?
 
sb247 said:
When the govt takes on the moral hazard of deciding who is good enough to be a medical decision maker for the "non trained" masses, they do so under the premise that others don't have to think about who their medical professional is because the govt does the screening for them. That's why they need to be all in or all out. Prior to midlevel independence it was "the medical professionals you can trust are these doctors" then with legislative changes it became "oh yeah, and also these NPs are just as good, trust us"

And the govt it wrong
Click to expand...
Better start picketing naturopaths if you're out here as a humanitarian. We can go together, I'll pack some lunches. Let me know when you're free.
 
sb247 said:
When the govt takes on the moral hazard of deciding who is good enough to be a medical decision maker for the "non trained" masses, they do so under the premise that others don't have to think about who their medical professional is because the govt does the screening for them. That's why they need to be all in or all out. Prior to midlevel independence it was "the medical professionals you can trust are these doctors" then with legislative changes it became "oh yeah, and also these NPs are just as good, trust us"

And the govt it wrong
Click to expand...

You’re really flailing here.

You’re fine with a medical free for all, but if the government provides any resources you no longer trust people to choose things for themselves?

Your arguments only work when you stick to your libertarian orthodoxy.

Realize your mistake here or you might have to admit your whole philosophy is bull****. I mean, you even support segregation from a libertarian angle - if you start making exceptions here, you should probably be rethinking things there too.
 
the "physician shortage" is a fallacy. now the unbalanced *number of patients without insurance or from other countries* is the problem.
 
IknowImnotadoctor said:
I'll try though. Here's an article by an MD...
Click to expand...

Why not use the meta analysis data that's available? We have all already seen the results: NPs make patients happy and are great for HCAHPS, reduced admissions, and relative mortality (though not different from an ordinary licensed nurse), and everything else--including overall cost--is equivocal. The confidence intervals are incredibly tight.

The results taken together tell us that NPs are not proven to be a necessary element in medical services that adds to patient welfare or reduces costs (as they often claim). Yet the nursing organization continues to be heavily invested in ensuring that NPs do have a place and are welcome to practice medicine. It's all been a push for a niche (jobs.) on the basis that nurses are already part of the medical establishment and can make inroads from the inside unlike alternative medicine practitioners.
 
atomheart said:
Why not use the meta analysis data that's available? We have all already seen the results: NPs make patients happy and are great for HCAHPS, reduced admissions, and relative mortality (though not different from an ordinary licensed nurse), and everything else--including overall cost--is equivocal. The confidence intervals are incredibly tight.

The results taken together tell us that NPs are not proven to be a necessary element in medical services that adds to patient welfare or reduces costs (as they often claim). Yet the nursing organization continues to be heavily invested in ensuring that NPs do have a place and are welcome to practice medicine. It's all been a push for a niche (jobs.) on the basis that nurses are already part of the medical establishment and can make inroads from the inside unlike alternative medicine practitioners.
Click to expand...

Why would I post an article written by an RN? None of you would read it and would knee jerk call it heresy.
 
Well, in case you did not know, there are more females in the world than there are males. It was just a matter of time. The probabilities that there would be more women in medical school are higher based on population alone.
 
IknowImnotadoctor said:
The NP group had a higher chance of being rural, were more often male and were more likely Medicaid patients with lower SES. All of these factors significantly increased their risk. The groups weren't "split" the study was simply describing the patient panel, nor did they say how significant the differences were. Find me a perfect study, and a unicorn and an honest politician while you're at it. Even better, find me a study that supports your position, doc.
Click to expand...

Younger, less co-morbid, less complex, vis-a-vis healthier. Where are you drawing high risk from that?
You're saying there is no 'unicorn' study... that's not the point. It's that you are drawing a conclusion of equivalency when the paper CLEARLY states the two groups were NOT equal in either demographics or risk propensity. You actually CAN'T draw a conclusion, but if you did, it would have to be that an APP can safely take care of less sick people. Yay? Certainly does not help your assertion
 
By accountability I mean that these individuals do not take as much pharmacology, if any, or other courses that are mandatory in medical school, thus they do not possess the knowledge that may compare to what MD's know. This means that they are not held to the same standards as MD's, yet they are given the same responsibility?????
 
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IknowImnotadoctor said:
I'll try though. Here's an article by an MD.

Process and Outcome Measures among COPD Patients with a Hospitalization Cared for by an Advance Practice Provider or Primary Care Physician

Do what you do; ignore the outcomes, focus on the limitations, and then tell me this study doesn't prove a thing because it's not absolutely perfect (even though no study is) ...
Click to expand...

One thing I don't get is why they didn't address (at all) their most obviously significant finding: Within 30 days, 78% of patients treated by MD's followed up with either their PCP or Pulmonologist, vs 62% of the patients treated by APP's (p = <.001; CI = 0.39 - 0.51). Instead, they report how 18% of MD patients followed up with a pulmonologist, while 20% of APP patients followed up with a pulmonologist (p = .01; CI = 1.07-1.48).

They didn't mention anything about this. Instead, we get "patients cared for by APPs had more clinic follow-up visits with a pulmonary specialist than the patients of MDs. Higher follow-up rates with pulmonologist post hospitalization in APP group may partly explain the lower trends in emergency visits and readmission." They go on to say "Studies have shown that early follow up with a pulmonary physician is associated with lower readmission rates," and then cite a study that actually says follow up with EITHER A PCP OR PULMONARY PHYSICIAN is associated with lower readmission rates, and that study didn't differentiate between the two.

I mean, you can't make this stuff up. It's like finding a study that claims, "having a republican or democrat in the office is good for our country," and then using that as a source to claim, "studies have shown that 'having a republican in the office is good for our country'" in an anti-democrat review.

Maybe, just maybe, the lower readmission rates have something to do with the APP group receiving patients with less co-morbidities and being of a younger age? Nah, I'm sure it's because APP's have more 'feelz' for their patients than those lower-quality MD's.
 
irJanus said:
Younger, less co-morbid, less complex, vis-a-vis healthier. Where are you drawing high risk from that?
You're saying there is no 'unicorn' study... that's not the point. It's that you are drawing a conclusion of equivalency when the paper CLEARLY states the two groups were NOT equal in either demographics or risk propensity. You actually CAN'T draw a conclusion, but if you did, it would have to be that an APP can safely take care of less sick people. Yay? Certainly does not help your assertion
Click to expand...

Doc, the comorbid scores were not that far off, 76.28 versus 71.94. In fact, some of the breakdown specific scores were higher for the NP's than the MD's, for instance, NP's had higher rates of renal failure, metastatic cancer, depression, AIDS, and obesity, which is very significant for COPD, than the MD panel.

No study is perfect, however this study does add to the discussion that NP care is safe, and it was authored by a physician which should lend it credibility in the medical community.
 
johnnydrama said:
Pretty sure there are unaccredited residencies you could choose from without funding. Just look at the types of things available to FMGs outside the match.

And you could refuse to receive your part of that government money, I’m sure the hospital would be happy to keep it.

Live your ideals. No one is forcing you to take government money.

Residencies before GME funding often charged for the privilege of training you, don’t you want to go back to those days free from government intervention?
Click to expand...
I would be just fine with going back to all of us paying for whatever training our particular group requires of us.....I'm all good with a free market approach to this
 
Fission Chips said:
One thing I don't get is why they didn't address (at all) their most obviously significant finding: Within 30 days, 78% of patients treated by MD's followed up with either their PCP or Pulmonologist, vs 62% of the patients treated by APP's (p = <.001; CI = 0.39 - 0.51). Instead, they report how 18% of MD patients followed up with a pulmonologist, while 20% of APP patients followed up with a pulmonologist (p = .01; CI = 1.07-1.48).

They didn't mention anything about this. Instead, we get "patients cared for by APPs had more clinic follow-up visits with a pulmonary specialist than the patients of MDs. Higher follow-up rates with pulmonologist post hospitalization in APP group may partly explain the lower trends in emergency visits and readmission." They go on to say "Studies have shown that early follow up with a pulmonary physician is associated with lower readmission rates," and then cite a study that actually says follow up with EITHER A PCP OR PULMONARY PHYSICIAN is associated with lower readmission rates, and that study didn't differentiate between the two.

I mean, you can't make this stuff up. It's like finding a study that claims, "having a republican or democrat in the office is good for our country," and then using that as a source to claim, "studies have shown that 'having a republican in the office is good for our country'" in an anti-democrat review.

Maybe, just maybe, the lower readmission rates have something to do with the APP group receiving patients with less co-morbidities and being of a younger age? Nah, I'm sure it's because APP's have more 'feelz' for their patients than those lower-quality MD's.
Click to expand...

They didn't include that finding in the conclusion because of the confounding variables you just listed. Don't call them out for concluding something that they actually didn't statistically conclude.
 
IknowImnotadoctor said:
Better start picketing naturopaths if you're out here as a humanitarian. We can go together, I'll pack some lunches. Let me know when you're free.
Click to expand...
I have called my various representatives about naturopaths too.....I guess we at least found one thing to agree on
 
sb247 said:
I have called my various representatives about naturopaths too.....I guess we at least found one thing to agree on
Click to expand...

Do you like PB&J? I'll pack the lunches. I know a few naturopath clinics we can start at.
 
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