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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.
I'm going to push back on the assumption that nurse practitioners, or even registered nurses, tend provide worse care than doctors for most patients. I want something more than an impression of anecdotes--preferably actual studies--because in my circle complaining about getting misdiagnosed made by doctors is a well-honed pastime.
I dig your take that those born to the PMC class who strive for Doctor status don't downgrade to nursing. In my experience, nursing Bachelors programs are still very competitive, and there are plenty of children of PMC that go into it (heck, I know a few). These are young women (for the most part) who like to work with people, who like clearly meaningful work, who are not put off by the prospect of hard work, and who by-and-large aren't strivers.
Nursing Bachelors programs also draw plenty of (mostly) women from the working class--because it's clearly meaningful and hard work that's well-renumerated--and only the smartest and most conscientious tend to make it into--and then through--the competitive Bachelors.
It therefore seems to me that there is a positive selection for a combination of conscientiousness, intelligence, and willingness to work hard. So without looking more into the data on the subject, I predict that a study comparing rates of misdiagnosis would be similar for Nurse Practitioners and Doctors, and probably not much worse for Registered Nurses.
Especially if the study counts the final diagnosis of the system rather than the initial diagnosis: a good Registered Nurse can look at a first-time patient, say "I think it's anxiety, but since I am not certain, so please wait while I consult with the Doctor on staff", and that may be the right call when the Doctor then identifies it as a blood clot. A good diagnosis by Registered Nurse should be "I know it's this" or "I need to send it up the chain of specialization".
(My thanks to @ToaKraka for posting earlier the info on what various nursing type professions require.)
This is an area of ongoing research, for a long time there was a bunch of non-inferiority type studies published by the nursing lobby which were apples to oranges comparison. Ex: NPs with simple cases and MDs with hard cases had similar outcomes.
Now that the NPs have made such a mess of things you have more research such as this: https://www.ama-assn.org/practice-management/scope-practice/3-year-study-nps-ed-worse-outcomes-higher-costs#:~:text=The%20study%20found%20the%20physician,complexity%20of%20the%20patient's%20condition.
It's important to keep in mind that NPs get effectively no training. Even if you think medicine is grossly simple (which....sigh), you should have some training.
I think people really struggle to understand how big the gap is no matter how often it's pointed out. You wouldn't trust Juan the day laborer working construction with designing a skyscraper, but that's a reasonably apt comparison in training differences and amounts.
NPs don't save the healthcare economy because while they do get paid less they do more unnecessary testing, it's just a wealth transfer from MDs to hospitals. They also stress the system more with unnecessary consults and admissions which only makes the doctor shortage issues worse.
That AMA link gives such a laughably biased summary of the actual study, though. The paper itself suggests a far more nuanced picture than your metaphor about Juan the day laborer-- and that's a study led by an MD who presumably has his own professional axe to grind. (I'd be much more interested in seeing some adversarial MD-DNP research collaborations in this area.)
Notably,
- The study focused almost entirely on costs in an ED setting; on a skim, I can't find that it examined detailed health outcomes at all beyond 30-day mortality and "preventable hospitalization," the latter of which seems difficult to define in terms of patient welfare. They say NPs and MDs had no significant differences in 30-day patient mortality.
- The study did find that treatment by NPs cost the system more than treatment by MDs, owing to NPs calling for longer hospital stays and more tests. But the difference in costs diminished with more experienced NPs.
- The cost difference also diminished to a relatively trivial level for less complex cases, and the authors themselves suggest that this means NPs could be valuable substitutes for physicians in primary care.
- They found almost as much variability in productivity from clinician to clinician *within* professions as there was *across* professions. Money sentence from the abstract: "Importantly, even larger productivity variation
exists within each profession, leading to substantial overlap between the productivity distributions of the two professions; NPs perform better than physicians in 38 percent of random pairs."
I agree with you that NPs receive a disturbingly small amount of training before they're turned loose on patients. But I think the question we should be asking is what it suggests about doctors' care if MDs still realize such minor gains over DNPs.I mean you are always going to run into study design limitations. In this case most of the money in medicine wants NPs to look good so there isn't good funding for this. The VA (generally) has pretty much the worst healthcare in the country and the quality of care in the ED is also pretty much the worst in the hospital (because of how it gets misused). This is likely to flatten the curve a little bit - good doctors almost never work at the VA.
Psychiatry is a better example - psychiatric interviews and pharmacology are the most complicated in medicine. Mental health care NPs are terrible at both of these things, give people unnecessary medications and incorrect diagnoses and are legible experienced as lower quality by patients and staff with some regularity. In general hospital medicine nurses line up each other and that includes NPs but in most mental health care settings nurses will say they think the NPs are shit.
However the bad outcomes are mostly increased lifetime mortality and risk of side effects 20 years down the line when the patient is seeing someone else. This becomes effectively impossible to study so we don't.
Now you could argue that you don't really care about those problems and if its not obvious their is a skill difference in outcomes lets save money, who cares if people have the wrong medication or diagnosis. But that goes back to the ED stuff - you have a difference in mortality and morbidity, it may be small but most Americans value "the best possible" not "good enough."
Also, since this is why people normally bring it up - if you magically paid all doctors NPs salaries and didn't really change anything else......healthcare costs wouldn't go down at all in any substantive way.
I should emphasize that I have a lot of respect for psychiatrists, who seem to hurl themselves into the breach of various social ills in a way I certainly wouldn't want to do. But if we're searching for a test field where rigorous evidence makes it very legible which are the "necessary medications" and "correct diagnoses," so that MDs' highly effective healing practice contrasts clearly with NPs' useless flailing, then I'm not sure psychiatry is the obvious pick. We're talking about the same psychiatry that regularly diagnoses from subjective surveys and patient self-reports, correct? Where almost none of the biological mechanisms are thoroughly understood, either for the ailments being treated or the medications that treat them? Where exercise, healthy diet and getting plenty of sun/fresh air seem to work as well as the best drugs a lot of the time? Where official medical conditions pop in and out of the DSM with every passing political wind?
Would you say that psychiatry does a good job of monitoring its physicians' contribution to patients' lifetime mortality and/or risk of third-order side effects 20 years out, either across different levels of physician talent/conscientiousness, or versus not receiving psychiatric care at all?
I don't quite get the reasoning here. Is the idea that receiving NP salaries would cause physicians to practice as badly as you believe NPs practice, because all the competent MDs would decamp for higher-paid professions (notwithstanding the additional benefits of prestige, flexibility, autonomy and meaning in medicine)? Doctors in Canada, the UK and Germany earn about 1/3 to 1/2 what they earn in the US; is the contention that they must practice incompetently and waste a ton of money doing so?
It's called the art and science of medicine for a reason, in psych it can be pretty evident to the lay man, in other specialties it's less but still present. This means experience, heuristics, gestalts, they lead doctors astray yes, but for a lot of things we don't have good guidelines or understanding.
Importantly, doctors can be sued - this causes all kinds of problems but it does serve as a feedback mechanism that assess for problems and gives patients recourse.
Let me give a specific example of how this happens, sticking with psych because it's more interesting than me mumbling about open vs lap vs conservative appendix management.
Most people are aware of Bipolar disorder, at least superficially. Lots of people say "I have mood swings" and tell that to healthcare workers with less training, these people dutifully write down Bipolar in the chart. Or they say "you ever like have mood swings and be unable to sleep?" Gets the diagnosis. Someone who actually has Bipolar 1 with a manic episode barely sleeps for a week of more, does illegal things, or spends ALL of their money in the bank account and all kinds of other stuff. The diagnosis is serious and life limiting without treatment. The medications are also serious - most patients get antipsychotics these days which increase all cause mortality. They are worth it if you actually have the disease. Put undertrained staff give the dx to people who don't have it and then suddenly...
NPs also do things like mix benzos and stimulants, put people with depression or anxiety on antipsychotics which will result in an early death....just all kinds of ridiculous stuff.
The skill ceiling in psych (and medicine) is very high, but if you don't work in healthcare you'll (hopefully) never see it come into play. Most medical work isn't your quick annual physical with your doctor but for many patients (especially young ones) that's all you see.
As for the second point, no the issue is that physician salaries are less than 10 percent of healthcare spending, and it's been decreasing every year. Cutting doctor salaries does not solve the problem and introduces all kinds of new problems.
Likewise NPs don't save money because they do more unnecessary testing and over consult, which drains the specialists and slows down care.
OK, this is a good example for illustrating the difficulty I'm having with the binary MD-competent/ NP-incompetent model. So here we have a fairly clear, potentially dangerous error in practice. Insofar as it is fairly clear, you were able to explain it to me in a paragraph or so: now I, a random Mottizen, understand that it's bad to diagnose and medicate bipolar just on the basis of "mood swings" or "poor sleep," and that patients should instead be experiencing very florid manic episodes with clear life consequences. That's facile, but for someone going on to psych practice, I'd imagine a few additional hours of video case studies would eliminate the lowest-hanging 80-90% of obvious mistakes of the form "don't diagnose bipolar in this clearly not-bipolar patient, dummy." So presumably that same advice and video training could be administered to a DNP before they begin psych practice, problem solved.
Fine, says the MD, but what about the top-10% "art of medicine" situations where the line is far more nuanced? There aren't empirical tests to verify a diagnosis; what if the situation sounds right on the border? The precise mechanisms of bipolar are poorly understood; what if there are a lot of other things going on and it's not clear how they interact? Or it's not clear how medication will impact any particular patient, so what if the risk-benefit math around prescription is very challenging?
I can easily see how what you call the "skill ceiling" could come into play there, leading an NP to get those questions wrong. What I don't see is the training value-add that makes you confident a random board-certified psychiatrist would clear the skill ceiling and get them right. There's not good basic science around these issues, so the organic chemistry and anatomy from med school certainly won't help. Residency? Presumably this means that the MD encountered some difficult cases under supervision and was admonished to approach each case the way their attending would do it. However, (a) that could have been an indefinite amount of time ago, and there's nothing beyond some trivial online quizzes to ensure the MD has kept up with new data since their training; and (b) even back in training, nobody was checking to make sure the supervisor was themselves particularly judging the situation "correctly". Indeed, how could anyone even define "correctly," if the case was by definition so difficult and subtle, the kind of situation where the wrong call would just make a patient sadder and less functional 20 years hence, not cause them to keel over and die on the spot? Doubtless the attending felt confident that their approach was making a real difference; but we all know the various cognitive biases that would lead doctors to overestimate the correctness of their judgment and the effectiveness of their treatment under those circumstances.
I guess it boils down to the broader question "when psychiatry works clearly, it should work for DNPs too; but when it doesn't work clearly, how can you be sure it works at all?" One established answer is to turn to empirical investigation to discipline our judgment; but as you point out, psychiatry isn't a field with a lot of options for carefully blinded RCTs and massive long-term studies.
I think people in other fields fail to understand how egregiously poor a lot of NPs are. Most settings they are still supervised or deliberately have low complexity cases sent their way or have some other aspect of the environment that protects them (for instance inpatient NPs just consult specialists for everything and those specialists manage the patient even though the NP is on charge on paper).
Surely they must have some training, and they can't be that bad, right? Like who would let them practice if they are that bad?
They are that bad.
It's been hard to extract the data about this because of financial interests in NPs, and the general difficulty of doing medical research.
So much of medicine is opaque to those outside the field and even inside of it (I know nurses who have been working for 40 years and go "huh" when you tell them the resident has been working 24 hours in a row).
Fundamentally I see midlevels every week who make decisions that would make me go "holy shit you are the worst doctor in your specialty I've ever met," it's near constant.
It sounds histrionic and unbelievable but that's how so much nonsense in healthcare is.
Amazon, google, apple, tons of finances firms have all come into medicine and gone "damn that shit is run so poorly surely we can do better" and then run away screaming.
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