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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 not sure that’s all bad. For the most part, medicine on a family practice level is pretty simple. It’s routine physicals, vaccinations, and common diseases about 80% of the time. The issue is less a NP or PA can’t handle that kind of workload than he or she is not handing off edge cases to doctors. If they were properly handling cases where patients had more complex symptoms or were complaining of serious pain with no known cause, there wouldn’t be much of an issue. Furthermore, wasting the talents of a full fledged doctor on walking into a room where a kid has a fever and runny nose and telling him he has the flu is a waste of the patient’s money and the doctor’s time. Doing routine vaccinations and physicals is likewise a waste of a doctor’s time and a patient’s money. And I don’t think at that point adding a bunch of doctors fixes the issue. You could do what happens in a dentist office in medical offices with no loss of care. The nurse does all the routine work and the doctors look over the data and only talk to the patients if there’s something more complicated than basic medical care needed.
Is it still a waste if the doctor is someone with a 120 IQ who would have got into medical school in the alternative system but ends up as a replacement-level software engineer in the US system as it is? The work of a GP in the British NHS, or in a well-run HMO where paid-for access to specialists is gatekept, does require more knowledge than an NP/PA, because you are gatekeeping access to specialists, so you need to know at least enough cardiology to know when to call the cardiologist etc. And the people doing that work don't seem to think it is meaningless - the complaints of British GPs are about pay and workload, not about the nature of the work. What it doesn't require is a gunner personality (except in so far as you need to deal with the rigours of residency) or a 130+ IQ.
FWIW, NP-equivalents in the UK are mostly people whose IQ is too high for nursing but were incorrectly sorted into it (I suspect, but don't know, that we make more errors of the "poor therefore stupid" type than the US does) and want a low-risk route to something better. My experience dealing with them (asthma care is handled by NP-equivalents, as is uncomplicated diabetes after initial diagnosis) is that they are as good as a GP within their scope of practice, as long as the understand the limits of said scope.
I’m not sure I’m following you here. I’m not talking about someone who doesn’t get into med school. I’m talking about a typical medical office visit in a family practice where the doctor doing much more than backstopping the NP or PA is in fact a waste of time simply because you don’t need 8 years of college and a couple years of residency to read blood pressure, heart rate, or oxygen levels. You don’t need that level of education for minor issues. I had a spider bite and needed to get an antibiotic for it. Nothing about that visit required a full fledged doctor to personally see me or prescribe antibiotics (other than liability issues and legal stuff) for a fairly minor complaint.
As such, I don’t see why it’s a problem that someone who didn’t go to medical school goes into software. It’s not going to make much of a difference in terms of the kind of care that I’m talking about. Probably 90% of medical care is pretty routine.
You don't train for routine issues, you train to know when an issue isn't a routine issue (and for how to deal with it).
If a patient comes in with abdominal pain, some times they need to fart and sometimes that person is going to die if they don't get transferred to a hospital immediately. You do the training so you don't get this decision making wrong, because society has decided it is unacceptable for us to get this wrong (which...fair).
Complicating this is the way that our regulatory and billing burden constantly pushes back against correct clinical practice, the science and practice are being always updated, and patients are grossly unreliable/muddy the waters.
Do keep in mind that a huge portion of clinical practice is not outpatient practice. What happens in a hospital is wildly different.
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