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Notes -
You Did It To Yourself
Again, the endless seething by doctors over their ongoing replacement by “physician associates/assistants” (PAs) and “nurse practitioners” (NPs) rears its head. The many concerns that physicians have about NP/PAs are, of course, entirely valid: they’re often stupid, low-IQ incompetents who have completed the intellectual equivalent of an associates degree and who are now trusted with the lives of people who think they’re being cared for by actual doctors.
Story after story describes the genuinely sad and infuriating consequences of hiring PAs, from grandparents robbed of their final years with their families to actual young people losing 50+ QALYs because some imbecile play-acting at medicine misdiagnoses a blood clot as “anxiety”. Online, doctors rightfully despair about what NPs are doing to patient care and to their own ability to do their jobs.
But there’s a grand irony to the nurse practitioner crisis, which is that it is entirely the making of doctors themselves. If doctors had not established a regulatory cartel governing their own profession, the demand that created the nurse practitioner would not exist. The market provides, and the market demanded healthcare workers who did the job of doctors in numbers greater than doctors themselves were willing to train, educate and (to a significant extent) tolerate due to wage pressure. It is a well-known joke in medical circles that doctors often have a poor knowledge of economics and make poor investment decisions. This is one of them; the market invented the nurse practitioner because it had to. Now all of us face the consequences.
I had multiple friends who attempted to get into medical school. Some succeeded, some failed. All who tried were objectively intelligent (you don’t need to be 130+ IQ to be a doctor, sorry) and hard working. The reason those who failed did so was because they lacked obsessive overachiever extracurriculars, or were outcompeted by those who were unnecessarily smarter than themselves (there is also AA, especially in the US, but that’s a discussion we have often here and I would rather this not get sidetracked).
The problem goes something like this: smart and capable people who just missed out on being doctors (say the 80th to 90th percentile of decent medical school candidates, if the 90th to the 100th percentile are those who are actually admitted) don’t become NPs/PAs. This is because being an NP/PA is considered a low-status job in PMC circles; not merely lower status than being a doctor, but lower status than being an engineer, a lawyer, a banker, a consultant, an accountant, a mid-level federal government employee, a hospital administrator, a B2B tech salesman etc, even if the pay is often similar. To become a PA as a native born member of the middle / upper middle class is to broadcast to the world, to every single person you meet, that you couldn’t become a doctor (this isn’t necessarily true, of course). This means that NPs and PAs aren’t merely doctor-standard people with less training, they’re from a much lower stratum of society, intellectually deficient and completely unsuited to being substitute doctors (the work of whom, again, doesn’t require any kind of exceptional intelligence, but it does require a little). Almost nobody from a good PMC background who fails to get into medical school or, subsequently, residency is going to become a PA/NP for these reasons of social humiliation, even if the pay is good.
Nobody who moves in the kind of circles where they have friends who are real doctors, in other words, wants to introduce themselves as a nurse practitioner or physician associate. A similar situation has happened in nursing more generally. Seventy years ago, smart women from good backgrounds became nurses. Today some of those women become doctors, but most go into the other PMC professions. Nursing became a working class job, and standards slipped. Still, nursing is still often less risky (although there are plenty of deaths caused by nurse mistakes) than the work undertaken by NPs and APs. Nursing became if not low status then mid status, and is now on the level of being a plumber or something - well remunerated, but working class.
The result is a crisis of doctors’ own making. Instead of allowing (as engineers, bankers and lawyers do) a big gradation of physicians, all of whom can call themselves the prestige title doctor but who vary widely in terms of competence, pay and reputation in the profession, doctors have focused on limiting entry, reserving their title for themselves and therefore turning away many decent candidates. (Of course there is a status difference between a rural family doctor and a leading NYC neurosurgeon, but the difference between highs and lows is different to the way it would be if medical school and residency places were doubled overnight.) The karmic consequence of this action is that they are now being replaced by vastly inferior NP/APs who deliver worse care, are worse coworkers and who will ultimately worsen the reputation of the broader medical profession.
What will it take to convince the medical profession, particularly in the US, to fully embrace catering to market demand by working to deliver the number of doctors the market requires, rather than protecting their own pay and prestige from competition in a way that leads to ever more NP/APs and ever worse patient outcomes? The US needs more doctors, especially in disciplines like anaesthesiology, dermatology and so on paid $200k a year (which, much as it might make some surgeons wince, is in fact a very respectable and comfortable income in much of the country). Deliver them, and the NP/AP problem will fade away as quickly as it began.
Lol I think about the same thing from time to time.
Back when I moved to a new area and had to face the terrifying fear of finding a new doctor, dentists, etc. all on my own, I spent a couple hours of research to find a doctor who accepted my insurance, was located conveniently close to my home, and seemed sufficiently competent from the dubiously reliable reviews and ratings systems there are for doctors (this shouldn't be difficult? There should be some easy way to ascertain if they've ever fucked over a patient or not?). The appointment had to be made a month or so out. I saw him a grand total of twice. Each time I waited about 20 minutes to be seen. I think I spent a total of 15 minutes in his presence. The first time he asked me all the standard health screening questions, including Tobacco use. I truthfully said that I'd had a cigar earlier that year, which he marked down on my sheet and noted "that might make it harder for you to get life insurance." Sent me to go get the standard battery of tests one gets as part of a general physical exam.
Second time, X months later I came back so he could review lab test results with me. All seemed good (BMI a little high but I COULD HAVE TOLD YOU THAT), and I requested politely that he make it clear that I am not a tobacco user, and he was good enough to remove that from the sheet. Hours of research and waiting to talk to the guy for <15 minutes and be told I'm in great health, if a little heavy.
Never went back. Felt like the time investment was simply not worth the so-called 'preventative' benefits. What was the point of him and me being in the same room other than allowing him to show face and justify however much he was billing to my insurance co.? Every single measurement he took could have been done by a nurse, any information he needed to diagnose could be provided without me having to make the appointment and such. I can give a blood sample, turn my head and cough, and get X-rays done somewhere else and send them to him for review without needing to coordinate our busy schedules to coincide.
That's how lab tests work! I go to a location that has plentiful availability, they do some tests and send the results to the Doc. Surely he could have looked them over and sent back some recommendations or concerns as needed. He can presumably do that from the comfort of his home, even!
If I feel something physically wrong with me and it doesn't go away, I go to urgent care and get attention on the spot. If I want to know about some given metric about my body I can usually purchase or borrow a tool that will give me acceptable measurements, then punch those into google (or, more recently, ChatGPT). As somebody with no chronic health issues I simply don't see the value-add of having a primary doctor that will just tell me things I already know, but with the authority of an M.D.
I donate blood every few months and they do a mini-physical that allows me to have a small insight into my health going back for years, so its not like I'm just sticking my head in the sand!
Now, OTOH I kind of love my Dermatologist. Visits last <30 minutes, about 10 of those she's physically present, and the entire time she's actually doing examination of the relevant organ. I pay in cash, I get another appointment 1 year out, and that's that. If something out of the ordinary is noticed, she can write the scrip and I can usually physically see the improvement the treatments bring.
I wonder how much of the prestige for doctors is still driven by all the Primetime shows that portray doctors as various types of savants or at least dedicated, hard workers who are subject to insane pressures and generally rise to the occasion. It probably makes the layperson think its GOOD that we limit who can be a doctor. "Doctors have to be like top 10% for intelligence and capable of working insane hours, that's not something just anybody can do!!"
Nevermind that the shortage of doctors is the reason they get insane hours and plenty of people in the top 10% for intelligence would avoid the field BECAUSE of that.
Why give blood every few months? Is that not excessive?
I assume they're talking about blood donation, not blood tests. When you go to donate, they test a drop for iron, and after your donation they test for a bunch of other stuff.
Somehow they don't even have to test the drop these days. They get the iron level some other way.
There's something different about you...
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