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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.
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.
Thanks for sharing the study, it is really very good! Reading it was a Sunday well-spent.
The conclusions that the authors reach have a lot of nuance, and help explain both why so many people have negative impressions of NPs while others have positive impressions: the variability of the productivity[1] within each profession dwarfs the difference between the average NP and the average doctor.
The other useful estimate from the study: randomly pick an NP and a Doctor working for VA emergency department; 6 out of 10 times, the Doctor is more productive, 4 out of 10 times, the NP is.
I understand that VA hospitals have trouble attracting talented doctors, though I assume that they have similar problems attracting talent in other professions, NPs in particular.
If I were in charge of VA, I would make a rule that any doctor who got their license in any OECD country can work unsupervised (provisional on training on HIPPA or whatever other US-specific medical laws). Then get a whole bunch of H1 Visas for any doctor who wants to come work for VA for five years.
[1] "productivity" was operationalized as the total cost of care (negatively coded), including the cost for any avoidable hospitalization due to screwing up, which makes sense in the VA emergency department.
What do you gain from this? If the goal to decrease healthcare costs this doesn't do much. If it's to solve the shortage it also doesn't help that much.
I would love to know why you don't think it wouldn't help with the shortage. I figure that, having a shortage of doctors willing to work in VA, combined with doctors from other countries who are willing to work at VA because it will gain them the higher US pay + a path to US citizenship, would indeed alleviate shortage of doctors at VA. However, I am not a medical doctor, so what am I missing?
Coming in way too hot.
The VA has had hiring freezes for the last two years, to my understanding. So no traditional shortage there.
Hiring extra VA physicians does nothing for the general problems we have in any case (which isn't a traditional shortage).
VA had a hiring spree last year, in large part because of the expanding benefits from the PACT Act.
Your impression of a hiring freeze remains partly correct, because VA has budget shortfalls and plans to lay off staff:
I suspect that VA tends to paint a bleak picture to Congress as a standard operating procedure, in hopes of getting more funding. Though my nephew assures me from his VA experience that more funding would not go amiss.
So back to my off-the-cuff idea of importing doctors: my point is that any VA hospital that finds it challenging to attract a decent US doctor ought to be able to do what the private sector does. Right now, the VA follows AMA's standards, which require any non-US-trained doctor to do 3+ years of residency (plus other things) before they can practice medicine in US. Residency slots are, apparently, the bottleneck for US doctor supply in the first place.
My question is: just how crucial is it for someone already practicing as a doctor in a French or German hospital to do 3+ years of residency in US?
I've never met a foreign trained doctor who came to the U.S. with Medical School and Residency training in Western Europe. We might actually have reciprocity agreements for those countries, I don't know, I've never encountered one. Scott did his Medical School in Ireland IIRC, which is note quite the same. The vast majority of foreign doctors I've met are from Asia (mostly India) and do absolutely need retraining and will generally admit as such, however frustrating it is.
Every time this comes up I have to drag out a few facts.
-There is actually a surplus of residency spots. Yes you heard me.
-We do have something of a shortage of some specialties, but this can't adequately be solved by increasing spots without decreasing training quality.
-Nobody wants to go into primary care because it pays significantly less, is one of the harder jobs, and has been made less attractive by regulatory burden and other factors.
-Most jobs are in primary care anyway, aka most doctors work in primary care.
-Even within primary care we have more of an allocation problem than a shortage. Doctors train very hard and start their adult life late. They want to be in desirable locations so Iowa has a shortage but NYC does not.
-NPs and PAs were meant to fix this but make it worse - they still want to go into specialties (and can since they have no specialty training, they can just do what they want) and they still hang around the same urban areas.
-You could hypothetically fix this by importing a ton of foreign doctors but you'd have to enslave them and force them to work in the undesirable locations long term or they would just leave immediately when given the option.
-You can fix this using the resources we have by raising salaries to what incentivizes the behavior you want. Nobody wants to do this, they just want to continue giving doctors the pay cuts they've been getting for the last 20-30 years, even though doctors are not a high percentage of healthcare costs.
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