Should physicians let NP/PA take over primary care and anesthesia?

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Color me surprised to see any even remotely positive comment about psych NPs coming from you! Nice to see.

I do think many in this thread are not aware of current PA programs admission standards. I read a recent statistic that stated fully 50% of PA programs do not require direct healthcare employment anymore, but instead accept "volunteering" and shadowing as experience. I will try to find this citation, but I have personally met more and more DE PAs lately with little-t0-no experience beforehand. I know a person who is attending USC's PA program. They became an EMT ~3 months before applying for their "experience". This person thought about doing DE NP but decided against it because it would take longer (3 years instead of 2 years) and decided to go w/PA as the route is faster. I am not making this up.
But if you actually read the CASPA reports or look at the profiles of most programs, they generally have at least 2,000 hours of HCE upon admission. Some people go straight through, which is fine (most physicians have zero prior HCE and are functional within a few months of entering intern year), but most do not. I mean, there's also plenty of NP programs that have zero HCE requirement (direct entry nurse practitioner programs, such as those at Yale and Columbia) and many RNs jump right into NP school after graduation. So the idea that "NPs have years of experience first" is entirely incorrect in many cases. And the prior experience many have isn't exactly earth shattering- yeah, your five years at the VNA is totally going to help you be on par with a BC/BE physician after a few online courses and 650 hours of self-arranged clinicals that you do two days a week at some outpatient NP that might have almost as little experience as you to begin with. PAs are at least getting a full educational experience of reasonable quality during their second year of training. I mean, nurses like to rip on them, but a PA receives only a year less training than a physician going through an accelerated program- most PA programs are 27 months, all of which is at the advanced level and in hard sciences, while an accelerated MD/DO is 36 months. I really doubt that they are going to be incompetent as an assistant provider when they've got as many clinical months as an accelerated MD in the same conical environment as their physician counterparts. They've got an abridged preclinical curruculum, but that's why they aren't, and shouldn't become, truly autonomous providers. Compare that with NP programs that are part-time more often than not and largely full of fluff theory courses and it's pretty obvious that the winner in quality is the PA. Nurses have lower quality educations and a fraction of the advanced hours PAs have and want independence regardless.

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Color me surprised to see any even remotely positive comment about psych NPs coming from you! Nice to see.

I do think many in this thread are not aware of current PA programs admission standards. I read a recent statistic that stated fully 50% of PA programs do not require direct healthcare employment anymore, but instead accept "volunteering" and shadowing as experience. I will try to find this citation, but I have personally met more and more DE PAs lately with little-t0-no experience beforehand. I know a person who is attending USC's PA program. They became an EMT ~3 months before applying for their "experience". This person thought about doing DE NP but decided against it because it would take longer (3 years instead of 2 years) and decided to go w/PA as the route is faster. I am not making this up.

I will take someone who has only a few months as an EMT and standardized admissions minimums, standardized education in the medical model, and a standardized certification exam that at least approaches that of physicians over someone with five years of nursing experience and a completely unregulated education full of nursing theory courses and a couple hundred clinics hours.
 
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I can count on more fingers and toes than I possess the number of "large blunders" that occurred secondary to nurses or were prevented by physicians. Let's not go there.
 
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There are PAs that don't want to go near complex cases; they can admit that their training isn't sufficient enough to do so. Although they were educated in the medical model, their studies did not reach the depth and breadth of medical school. Also, there were classes in medical school that were not taken in PA school. That is what my fellow med student said. So, PA to MD/Do students still get overwhelmed.
 
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I didn't say anything about comparing our educations. And I actually do think midlevels have a role in subspecialty clinics - we have NPs in ENT that work well because they only need to know the differential and workup for their one area (dizziness, peds, etc) and once trained don't need much oversight. I do NOT think primary care is where they belong, because the breadth is too wide for them to ever master. They result in excessive tests, excessive referrals, excessive prescribing.

And you yourself are saying that there should be more QC - yet it is okay for these substandard NPs to be independent? And YOU may not practice independently right away, but is that true of all the other NPs (we both know that's not true). Don't you think there is some cognitive dissonance in what you're saying?

Truthfully I don't have all the answers - all I can hope for is that our profession continues to grow and elevate itself to higher standards. I continue to believe that what I'm doing is a service to the public and to the underserved. If you're so against nurse practitioners working in primary care, then as a physician what can you realistically propose we do as a society to alleviate the crisis in a country where millions of people who are now insured have no access to primary care services? Despite what you say, that nurse practitioners are not the best option, for some people we are the only option. And particularly, in areas where MD/DO are not available to do chart reviews or collaborative agreements, I fight for independence. It's that simple. I do not claim that our educations equivalent, and I do not claim that we are equivalent in all respects (though some good studies, despite what some of you posters are saying, show that we are equivalent in many respects) - I just claim and can prove with actual data (unlike you guys against this) that in primary care, nurse practitioners have a role and should be given practice authority in primary care (which they are in several states and D.C.). Many of you are probably threatened by this, but you shouldn't be. I (as most nurses) have a lot of respect for doctors, and know my place in complicated matters of medical decision making. I will never try to do more than what I'm capable of doing. Nevertheless, whether you like it or not, we will continue to grow as a profession, and will continue to lobby in government. There are a lot of nurses that feel the same way I do - a lot of physicians, administrators, policy makers, and the public, also would agree with the points I have brought up. Look at the Institute of Medicine (IOM) that called for nurses to practice at the full scope of their license and education.
 
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I do not claim that we are equivalent in all respects (though some good studies, despite what some of you posters are saying, show that we are equivalent in many respects) -

Except you did. And no, those studies aren't good studies. They are terrible studies, which you would know if you learned anything about research. I made a whole post about how studies that were actually good showed a stark difference in care, which you conveniently ignored.

I just claim and can prove with actual data (unlike you guys against this) that in primary care, nurse practitioners have a role and should be given practice authority in primary care (which they are in several states and D.C.).

I don't think anyone has said that midlevels don't have a role. You've claimed equivalence, which goes against the good evidence out there. We're saying midlevels should not be practicing independently unless you can be as good as physicians, which you're not and won't be (unless you all go to medical school).
 
Except you did. And no, those studies aren't good studies. They are terrible studies, which you would know if you learned anything about research. I made a whole post about how studies that were actually good showed a stark difference in care, which you conveniently ignored.



I don't think anyone has said that midlevels don't have a role. You've claimed equivalence, which goes against the good evidence out there. We're saying midlevels should not be practicing independently unless you can be as good as physicians, which you're not and won't be (unless you all go to medical school).

Hey, you know about those "fluff" courses we take in nursing school and NP school that you claim we have too much of in our curriculum? Well a few of those research and theory courses we take focus on just that: RESEARCH. The course I took in graduate school called "Research" was a graduate level course that focused on things involving grading research, creating research plans, and disseminating evidence based findings into practice (among several other things). That is what my courses in nursing theory and health promotion and disease prevention also taught..

You don't think I see the limitations of these studies? Do you know how difficult it is to measure and control all the components you are asking for in a study like this? You care so much about this, how about you publish a study? Nevertheless, I agree, the studies have their limitations (e.g., short follow up periods and lack of controls). Although outdated, there were well-publicized, well-conducted randomized trials conducted in the 1970s that proved the concept that an autonomous primary care APRN can deliver care comparable to that provided by a primary physician (Burlington Randomized Trial of the Nurse Practitioner, the St. John's Randomized Trial of the Family Practice Nurse). These studies may have made further proof of equivalence seem unnecessary, particularly since independent APRN practice in primary care and urgent care were widely implemented in many states and throughout the VA, where rigorous quality assessment has been applied since the 1990s. But with increasing complexities in primary care, definitely its clear that more studies that measure more variables need to be done with further quality assessment measures in areas like the VA where independent practice is present and data like this can be tracked (VA still does this). With that said, to date, all the studies I've come across are reassuring and have not shown any significant differences in the measures like practice patterns, frequency of tests ordered, quality of life, mortality, etc. Of note, there is a policy paper Newhouse and colleague and studies by Naylor and Kurtzman that I suggest you look at since you're all about good evidence. The data from the former and the later papers were major and corroborate what I've been arguing regarding independent ARNP practice. In fact, these were the studies that the Institute of Medicine and RWJF used to back up their calls for NPs to practice at the top of their licenses and their claims that there is no practice differences between the two groups.

Now read carefully "Foxy". Having said everything I just said, I'm still for the team based approach in a majority of the areas of medicine. Obviously, an NP will not practice independently in specialty areas. Of note, no NP I have ever met is against working with or for physicians. I (and most nurses) have a ton of respect for doctors and know our place in matters of complicated medical issues that are outside our scope..Need I repeat that? Because this is the 2nd or 3rd time I said this to you. In areas where there is decreased access to primary care services or same day visits; or where physician collaboration is highly inconvenient or impossible; or in general where access to health care services may be limited; my stance (and the stance of many others [i.e., physicians, nurses, administrators, the public, and policy makers]) is, and will be - until data says otherwise - that NPs should absolutely be allowed to practice autonomously. We know our scope and when to refer. I'm so convinced of this that 21 other states (and counting) and D.C. are making this a reality.

You mentioned that I "claimed equivalence, which goes against all the good evidence out there." Do you have data that negates any points I have made so far? Care to site anything?

All the best Dr. "Foxy".

Primary Care Outcomes in Patients Treated by Nurse Practitioners or Physicians
Evidence Brief: The Quality of Care Provided by Advanced Practice Nurses - VA Evidence-based Synthesis Program Evidence Briefs - NCBI Bookshelf
 
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'NPs to practice at the top of their licenses'

I like when NPs say that... What does that even mean? They all have the same buzzwords?
 
'NPs to practice at the top of their licenses'

I like when NPs say that... What does that even mean? They all have the same buzzwords?

Do you have an intelligent rebuttal for what I just said to Dr. "Foxy" up there or you just gonna be a d***?
 
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You make the comment that you have graduate level training in research, then mention bogus studies to "prove with actual data" that nps should be given "practice authority" in primary care.

Earlier on the comment was made that you don't feel comfortable upon graduation to be independent as a fully liscensed new np and wanted to work as part of a team in the beginning. If you don't feel ready for the job upon graduation, that shows the education is not enough to grant full practice rights.
 
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Exactly. Accreditation requirements before graduation differentiates workers who have experience in a field.

Accreditation holds the noose around the student before independence to ensure high quality. My own field is a three year model for recognition or Systemic problems that don't mimic nmsk problems appropriate for physiotherapy intervention as a first line of treatment (which AMA hates due to a different provider and billing contact point lol) but it works.

When you prescribe, you change pathophysiology. Med residency year is necessary to distinguish organic vs inorganic and subsequent tx. NP lobby has expedited that based on being cheaper to insurance and overall healthcare costs.

Is that true? Yes.

Does it mean an actual agreement has been reached by physicians and mids? No. It doesnt.

It's using the third party payment system system to establish jobs. Does it affect usual mean of patient services? Probably not. But it does hurt all of the zebras? Yes.

As someone in an allied health field which only has a very small independent market model of repetitive strain injury away from working with physicians, I can tell you that what I haven't seen before let loose is very heavy.

For some reason NPS think that dropping into the healthcare business model before seeing pathophys under guidance makes them equivalent to physicians simply because they are cheaper to insurance companies.

Accreditation standards force learning, thinking patterns, and recognition as well as pattern development under supervision.

NPS have the same legalities as physicians without the accreditation requirement.

That isn't the solution to PCPs. The solution is a three year MD model to residency.

You have the same tx as physicians without catching zebras? You stay a midlevel.

For those who don't know: zebras are the cases that aren't bread and butter

Can you be clearer with you language here? Not really sure what you're trying to say but first of all we are accredited. Nursing has it's own accrediting body and for NPs, it is the ANCC and/or AANP which requires renewal every 5 years with RN license renewal every 2 years. Second, there are studies where NPs and Physicians were compared independently (NPs without oversite) as far out as 2 year follow-ups post hospitalization and showing no significant differences in important measures. This has been done in urgent care settings as well with total randomization of patients seen by NPs and physicians. NPs have been key in increasing access to care. While I agree with you that we need more physicians, so far NPs have been safely filling the void.
 
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You make the comment that you have graduate level training in research, then mention bogus studies to "prove with actual data" that nps should be given "practice authority" in primary care.

Earlier on the comment was made that you don't feel comfortable upon graduation to be independent as a fully liscensed new np and wanted to work as part of a team in the beginning. If you don't feel ready for the job upon graduation, that shows the education is not enough to grant full practice rights.

These studies, to major institutions, including the IOM were not seen as "bogus." Again, as I said to Mathew9 above, it is difficult for any discipline to have no bias or limitations. Very difficult to measure all the variable and have all the inclusion criteria that you desire. The studies I cited were RCTs and are some of the best we have at the moment. The earlier classic studies are what prompted independent practice out west a while ago. Let me ask you, do you have anything better to site that can nullify the studies I've mentioned? Many of the studies out there had physician collaborators and authors. Notably, where there is a lack of data there is quality assessment in work places. For example, the VA conducts quality assessments that monitor the safety and quality of care provided by NPs. So far, only favorable results. And yes, I will not feel comfortable practicing independently right out of school. No NP really is. That's why no NP that I have ever met, or any employer (whether be physician or hospital or whatever) will hire someone right out of school to practice independently. When I talk about this, assume I am talking about experienced NPs in states (or locations like the VA) where autonomous providers have been studied. In the states that have independent NP providers, the data so far shows they are doing just fine.
 
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I never try to assume anything as much as I can help it.

That's the problem, we are asked to assume a level of competency.
 
I never try to assume anything as much as I can help it.

That's the problem, we are asked to assume a level of competency.

Well you're right, one should always be cautious about competency of a new hire (tbh whether be physician or NP, but more so with NPs obviously). If you are a physician hiring a NP to partner with; or if your in a position to hire, and you are in a state where NPs do practice "independently", then you should make sure that that new graduate NP is monitored. I would argue that all places of employment never assume that the NP is experienced. Obviously they're going to check that NPs credentials and experiences. They check and make sure the NP is competent before coming on board, or offer a "fellowship" type program for the new grads. For example, CVS has a new graduate program to monitor new NPs and VA has a residency before turning a NP loose. Every place I know of has some kind of system like this. And even when NPs are turned loose, they don't see very complex cases. And if it does get very complex, NPs are drilled in school to refer out and not practice beyond scope.. But yea, rest assured that no NP ever goes in out of school and practices independently...
 
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Can you be clearer with you language here? Not really sure what you're trying to say but first of all we are accredited. Nursing has it's own accrediting body and for NPs, it is the ANCC and/or AANP which requires renewal every 5 years with RN license renewal every 2 years. Second, there are studies where NPs and Physicians were compared independently (NPs without oversite) as far out as 2 year follow-ups post hospitalization and showing no significant differences in important measures. This has been done in urgent care settings as well with total randomization of patients seen by NPs and physicians. NPs have been key in increasing access to care. While I agree with you that we need more physicians, so far NPs have been safely filling the void.
He's saying that just because you're legally allowed to do something doesn't mean you're actually competent to do that thing. I can legally go take my car's engine apart right now and put it back together, but that does not mean I'm as competent as an ASE certified mechanic.
 
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Interesting posts from 2 DNP students:

From IknowImnotadoctor: ↑
I'm a DNP student in my 6th of 8 semesters. The masters program does not have the research focus to be able to evaluate a healthcare study. The DNP is a mini PhD/MPH/leadership hybrid. It is very well suited for the intent of the degree.

From AdmiralChz:
Fascinating... I continue to be disappointed with the lack of raw clinical didactics being taught in NP school. Instead it's often a focus on peripheral subjects like ethics - I understand the value I suppose in a nursing model but such online-based education doesn't carry the same academic rigor physicians go through, or even PAs for that matter unfortunately.

Except that all this doesn't only occur in online NP programs.
 
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Hey, you know about those "fluff" courses we take in nursing school and NP school that you claim we have too much of in our curriculum? Well a few of those research and theory courses we take focus on just that: RESEARCH. The course I took in graduate school called "Research" was a graduate level course that focused on things involving grading research, creating research plans, and disseminating evidence based findings into practice (among several other things). That is what my courses in nursing theory and health promotion and disease prevention also taught..

This says it all.
 
Interesting posts from 2 DNP students:

From IknowImnotadoctor: ↑
I'm a DNP student in my 6th of 8 semesters. The masters program does not have the research focus to be able to evaluate a healthcare study. The DNP is a mini PhD/MPH/leadership hybrid. It is very well suited for the intent of the degree.

From AdmiralChz:
Fascinating... I continue to be disappointed with the lack of raw clinical didactics being taught in NP school. Instead it's often a focus on peripheral subjects like ethics - I understand the value I suppose in a nursing model but such online-based education doesn't carry the same academic rigor physicians go through, or even PAs for that matter unfortunately.

Except that all this doesn't only occur in online NP programs.

At surface level, I'd have to somewhat agree with what the above comment says. I admit that NP programs leave many student's including myself wanting more (at least in regards to medical sciences)..I too wish we had more medical science courses and required more basic science courses. It is not a perfect education model but masters and doctorate programs are made the way they are by design and no just haphazardly slapped together. It is not a bad education at all for what it is trying to do. It is very well rounded and doesn't just focus on science and medicine. Because of how healthcare has shifted, in a direction with a much larger emphasis on health promotion and disease prevention, and with a much larger population to serve, masters nursing program tend to focus a lot on that. It is much better (and much cheaper for society) to prevent disease and promote good health strategies and compliance. The DNP (and to a lesser extent the MSN) goes deep into research statistics and healthcare policy because they are training not just for medical competency, but for leaders in healthcare. So yes, medical science courses in MSN and DNP program may not be as extensive, but that is because nurses are not just trying to become clinically savvy but to be leaders in healthcare, become researchers, and to advance the nursing profession. Maybe those DNP student's should go to medical school if they want more of a science focus. DNP program is not meant to mimic medical school but clearly has other foci in addition to fostering sound clinical skills (Sound clinical skills are evidenced by data. See the most recent reply above to Mathew9).
 
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He's saying that just because you're legally allowed to do something doesn't mean you're actually competent to do that thing. I can legally go take my car's engine apart right now and put it back together, but that does not mean I'm as competent as an ASE certified mechanic.

Please read my reply's to the others MadJack. We've covered a lot and just don't want to keep repeating my self. Here are some studies that may open your eyes a bit. Notice how the first randomized trial has physician authors and note the author affiliations (just thought that was interesting). These are not just NP ran studies...

1. Primary Care Outcomes in Patients Treated by Nurse Practitioners or Physicians
2. http://www.mc.vanderbilt.edu/documents/nursingoap/files/Quality of Primary Care Advanced Practice Nurses.pdf

With that said, I believe in this very much:

1.Working Together in the Best Interest of Patients
 
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Please read my reply's to the others MadJack. We've covered a lot and just don't want to keep repeating my self. Here are some studies that may open your eyes a bit. Notice how the first randomized trial has physician authors and note the author affiliations (just thought that was interesting). These are not just NP ran studies...

1. Primary Care Outcomes in Patients Treated by Nurse Practitioners or Physicians
2. http://www.mc.vanderbilt.edu/documents/nursingoap/files/Quality of Primary Care Advanced Practice Nurses.pdf
Again, none of these studies had equal time per patient, accounted for physician consultation, etc.
 
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And as to who wrote them- physician empowers have an incentive to prove equivalence. Physician employees have a disincentive to do so.
 
Again, none of these studies had equal time per patient, accounted for physician consultation, etc.

The randomized trial I cited doesn't account for time spent with the patients (however does account for follow-up periods which has time table and several other important measurements); but what is interesting is that because NP practices were opened up after the physician practices, and could accept more new patients into the practice, they had larger volume initially and overall, saw more patient's in this study. Both the physicians and the NPs were practicing independently and with equal access to referral, consultations, to prescribe, and to admit patients. This study is huge and adds a ton of weight and reassurance of NP competence, and only corroborates the weaker studies that came before it. In the comments of this study, it said this:

"Nurse practitioners have been evaluated as primary care providers for more than 25 years, but until now no evaluations studied nurse practitioners and physicians in comparable practices using a large-scale, randomized design. The results of this study strongly support the hypothesis that, using the traditional medical model of primary care, patient outcomes for nurse practitioner and physician delivery of primary care do not differ."


And as to who wrote them- physician empowers have an incentive to prove equivalence. Physician employees have a disincentive to do so.

This is an interesting theory (or not so interesting but silly), but hard for me to believe that there would be fowl play when studies like this have author affiliations to places like Harvard and Columbia. I think there is objectivity to these studies, especially the ones with authors from multiple disciplines (i.e., physicians and nurses).
 
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The randomized trial I cited doesn't account for time spent with the patients (however does account for follow-up periods which has time table and several other important measurements); but what is interesting is that because NP practices were opened up after the physician practices, and could accept more new patients into the practice, they had larger volume initially and overall, saw more patient's in this study. Both the physicians and the NPs were practicing independently and with equal access to referral, consultations, to prescribe, and to admit patients. This study is huge and adds a ton of weight and reassurance of NP competence, and only corroborates the weaker studies that came before it. In the comments of this study, it said this:

"Nurse practitioners have been evaluated as primary care providers for more than 25 years, but until now no evaluations studied nurse practitioners and physicians in comparable practices using a large-scale, randomized design. The results of this study strongly support the hypothesis that, using the traditional medical model of primary care, patient outcomes for nurse practitioner and physician delivery of primary care do not differ."




This is an interesting theory (or not so interesting but silly), but hard for me to believe that there would be fowl play when studies like this have author affiliations to places like Harvard and Columbia. I think there is objectivity to these studies, especially the ones with authors from multiple disciplines (i.e., physicians and nurses).
You realize Columbia is basically the heart of the nurse independence movement and Harvard is basically where the AHA leadership breeds out of, right?
 
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You realize Columbia is basically the heart of the nurse independence movement and Harvard is basically where the AHA leadership breeds out of, right?

Can you stop being so darn knowledgeable. It is becoming damn near impossible not to like EVERY one of your posts.

Really getting sick of these well thought out responses.
 
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You realize Columbia is basically the heart of the nurse independence movement and Harvard is basically where the AHA leadership breeds out of, right?

Yes, but basically you're suggesting that these studies are inherently flawed, even if they have physician authors, because the powers that be have incentive to do so. Do you know what it would do to these prestigious school's credibility and reputation if they publish studies that lack objectivity and rigor, or fraudulently publish data? They won't even a/w an author that doled out studies that were sh**. Again, an interesting theory, but really doubt its that simple.
 
Yes, but basically you're suggesting that these studies are inherently flawed, even if they have physician authors, because the powers that be have incentive to do so. Do you know what it would do to these prestigious school's credibility and reputation if they publish studies that lack objectivity and rigor, or fraudulently publish data? They won't even a/w an author that doled out studies that were sh**. Again, an interesting theory, but really doubt its that simple.
Why Biomedical Research Has A Reproducibility Problem – Footnote

Between 75 and 90% of biomedical research is not reproducible. This includes the major journals. Almost all researchers have a deep inherent bias that makes objective evaluation of the data difficult, so one must always look at a study critically. This is known as the reproducibility crisis. In physics, they solve it with large datasets that are randomly generated and mixed with accurate results and thus results are only selected when an author comes to the same conclusions as the correct set of blinded data (that's the easiest way to describe it anyway). Medicine has the amongst the worst track record of keeping data objective of any scientific field.
 
Why Biomedical Research Has A Reproducibility Problem – Footnote

Between 75 and 90% of biomedical research is not reproducible. This includes the major journals. Almost all researchers have a deep inherent bias that makes objective evaluation of the data difficult, so one must always look at a study critically. This is known as the reproducibility crisis. In physics, they solve it with large datasets that are randomly generated and mixed with accurate results and thus results are only selected when an author comes to the same conclusions as the correct set of blinded data (that's the easiest way to describe it anyway). Medicine has the amongst the worst track record of keeping data objective of any scientific field.

Im going to save that article and look it over. Though, I do already know that reproducibility is an issue. But that is extremely difficult to control no matter what you study and conclusions have been made in all areas of study, in spite of this. Nevertheless, the data we do have on NPs is quite compelling and is actually really reassuring.
 
Im going to save that article and look it over. Though, I do already know that reproducibility is an issue. But that is extremely difficult to control no matter what you study and conclusions have been made in all areas of study, in spite of this. Nevertheless, the data we do have on NPs is quite compelling and is actually really reassuring.
You find it compelling, I find it limited. I do have a good idea of how to study the issue properly though.
 
Please read my reply's to the others MadJack. We've covered a lot and just don't want to keep repeating my self. Here are some studies that may open your eyes a bit. Notice how the first randomized trial has physician authors and note the author affiliations (just thought that was interesting). These are not just NP ran studies...

1. Primary Care Outcomes in Patients Treated by Nurse Practitioners or Physicians
2. http://www.mc.vanderbilt.edu/documents/nursingoap/files/Quality of Primary Care Advanced Practice Nurses.pdf

With that said, I believe in this very much:

1.Working Together in the Best Interest of Patients

Sigh come on did you even read those papers? Did you look at what outcome measures they were using and at what time interval? You tell me, does it make sense to use those as a measure of quality care? This is what people mean when they say these papers are so blatantly written to advance an agenda rather than contribute to medicine or patient care.
 
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Sigh come on did you even read those papers? Did you look at what outcome measures they were using and at what time interval? You tell me, does it make sense to use those as a measure of quality care? This is what people mean when they say these papers are so blatantly written to advance an agenda rather than contribute to medicine or patient care.

The terrible outcome measures of this paper are really no different in quality than the vast majority of medical research studies measuring outcomes, really. These studies are pretty indicative of the overall quality of medical research in general. It's not the player here, it's the game.
 
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Hey, you know about those "fluff" courses we take in nursing school and NP school that you claim we have too much of in our curriculum? Well a few of those research and theory courses we take focus on just that: RESEARCH. The course I took in graduate school called "Research" was a graduate level course that focused on things involving grading research, creating research plans, and disseminating evidence based findings into practice (among several other things). That is what my courses in nursing theory and health promotion and disease prevention also taught..

You don't think I see the limitations of these studies? Do you know how difficult it is to measure and control all the components you are asking for in a study like this? You care so much about this, how about you publish a study? Nevertheless, I agree, the studies have their limitations (e.g., short follow up periods and lack of controls). Although outdated, there were well-publicized, well-conducted randomized trials conducted in the 1970s that proved the concept that an autonomous primary care APRN can deliver care comparable to that provided by a primary physician (Burlington Randomized Trial of the Nurse Practitioner, the St. John's Randomized Trial of the Family Practice Nurse). These studies may have made further proof of equivalence seem unnecessary, particularly since independent APRN practice in primary care and urgent care were widely implemented in many states and throughout the VA, where rigorous quality assessment has been applied since the 1990s. But with increasing complexities in primary care, definitely its clear that more studies that measure more variables need to be done with further quality assessment measures in areas like the VA where independent practice is present and data like this can be tracked (VA still does this). With that said, to date, all the studies I've come across are reassuring and have not shown any significant differences in the measures like practice patterns, frequency of tests ordered, quality of life, mortality, etc. Of note, there is a policy paper Newhouse and colleague and studies by Naylor and Kurtzman that I suggest you look at since you're all about good evidence. The data from the former and the later papers were major and corroborate what I've been arguing regarding independent ARNP practice. In fact, these were the studies that the Institute of Medicine and RWJF used to back up their calls for NPs to practice at the top of their licenses and their claims that there is no practice differences between the two groups.

Now read carefully "Foxy". Having said everything I just said, I'm still for the team based approach in a majority of the areas of medicine. Obviously, an NP will not practice independently in specialty areas. Of note, no NP I have ever met is against working with or for physicians. I (and most nurses) have a ton of respect for doctors and know our place in matters of complicated medical issues that are outside our scope..Need I repeat that? Because this is the 2nd or 3rd time I said this to you. In areas where there is decreased access to primary care services or same day visits; or where physician collaboration is highly inconvenient or impossible; or in general where access to health care services may be limited; my stance (and the stance of many others [i.e., physicians, nurses, administrators, the public, and policy makers]) is, and will be - until data says otherwise - that NPs should absolutely be allowed to practice autonomously. We know our scope and when to refer. I'm so convinced of this that 21 other states (and counting) and D.C. are making this a reality.

You mentioned that I "claimed equivalence, which goes against all the good evidence out there." Do you have data that negates any points I have made so far? Care to site anything?

All the best Dr. "Foxy".

Primary Care Outcomes in Patients Treated by Nurse Practitioners or Physicians
Evidence Brief: The Quality of Care Provided by Advanced Practice Nurses - VA Evidence-based Synthesis Program Evidence Briefs - NCBI Bookshelf
We're going to have a point-by-point discussion of why these studies are dumpster fires not worthy of publishing.

First, we will discuss the initial study. It was done with less than two thousand patients. That's less than a single doctor carries- how can you make broad generalizations based on the outcomes of around 1,200 total patients assigned to a NP? That's three fifths of a single provider panel, and furthermore, they were only followed for one year. I'm confident a literal high schooler with an UptoDate subscription would likely have equal outcomes on such a small scale with such a short time window. Finally, the outcomes measured are absolute trash. Patient satisfaction has a negative correlation with outcomes. The actual physiologic outcomes measured are on such a small scale and with such a short window that you'd have to literally be ******ed to screw them up within the time provided.

I'll get to the next study after my shift, but in summary- absolute and total trash that I wouldn't put literally any stock in.
 
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Sigh come on did you even read those papers? Did you look at what outcome measures they were using and at what time interval? You tell me, does it make sense to use those as a measure of quality care? This is what people mean when they say these papers are so blatantly written to advance an agenda rather than contribute to medicine or patient care.
I have avoided a point-by-point dissection thus far because I end up doing this with a NP literally twice a year about the same garbage studies and I'm tired of it. And in the end they always cede to, "well they're not good studies, but they add up to more than nothing!" And my response is that no matter how high you pile ****, it is still ****. This isn't research alchemy.
 
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Please read my reply's to the others MadJack. We've covered a lot and just don't want to keep repeating my self. Here are some studies that may open your eyes a bit. Notice how the first randomized trial has physician authors and note the author affiliations (just thought that was interesting). These are not just NP ran studies...

1. Primary Care Outcomes in Patients Treated by Nurse Practitioners or Physicians
2. http://www.mc.vanderbilt.edu/documents/nursingoap/files/Quality of Primary Care Advanced Practice Nurses.pdf

With that said, I believe in this very much:

1.Working Together in the Best Interest of Patients
Now, for the second study, the only part of the meta analysis that actually took place in the United States was the study I already took apart. The rest were foreign nurse practitioners, that have different educational standards and clinical training requirements, thus making them an apples to oranges comparison to begin with. Furthermore, the studies had a mix of sort durations, poor outcome measures, or outcomes that are highly unlikely to be applicable in the unique practice environment of the US.
 
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I have avoided a point-by-point dissection thus far because I end up doing this with a NP literally twice a year about the same garbage studies and I'm tired of it. And in the end they always cede to, "well they're not good studies, but they add up to more than nothing!" And my response is that no matter how high you pile ****, it is still ****. This isn't research alchemy.
Welcome to my world
 
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I have avoided a point-by-point dissection thus far because I end up doing this with a NP literally twice a year about the same garbage studies and I'm tired of it. And in the end they always cede to, "well they're not good studies, but they add up to more than nothing!" And my response is that no matter how high you pile ****, it is still ****. This isn't research alchemy.

Okay well if the randomized trial study is s***, then a majority of the medical/health science research out there is s*** Mad Jack. If you really want to be that critical with every single study, then sorry, but you'll never move anything forward in medicine either. You can't measure for every single variable. That is VERY difficult if not impossible. So you study a few variables at a time with each study. No one study measuring NP competency will ever have it all. What outcome measures would you suggest goes into a study like this?
This study while not perfect continued to shed light and advance research of ARNPs and their competency. It demonstrated this at several levels.. It provided more insight of their value in the healthcare system than what you're opinions and insights gave me on this forum over the last 3 days. Clearly, you have a bias and to stubborn to accept what is plain as day and in front of you.
 
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I'll have to agree that most of the healthcare outcome research out there is junk. But, it is data in a world of not so good data, so it does actually convey some information. I'm also fully on the side of, if you want to curb encroachment from midlevels, you actually need some quality data of your own, rather than relying on "this is the way it's always been done, so it's better because......things!" If you're going to call for better research, at least call for better research all around. Way too many people in glass houses throwing stones like they're on sale.
 
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I'll have to agree that most of the healthcare outcome research out there is junk. But, it is data in a world of not so good data, so it does actually convey some information. I'm also fully on the side of, if you want to curb encroachment from midlevels, you actually need some quality data of your own, rather than relying on "this is the way it's always been done, so it's better because......things!" If you're going to call for better research, at least call for better research all around. Way too many people in glass houses throwing stones like they're on sale.
All I want is better data. One hundred fresh NPs versus one hundred fresh physicians, no backup on the NP end, 10 year study duration, only objective outcome measures, analyzed by a third party with de-identified data. Kaiser could do it with new hires, it would be about the simplest and most straightforward data analysis ever performed. From there you could break down outcomes by patient population.
 
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I'm beginning to wonder if FNP has pre written responses to everything that might be said of the NP profession.

FNP is clearly on a mission, and it isn't to help students become doctors.

Regardless, NP's will never be MD's.
 
Holy crap. Okay.

Hey, you know about those "fluff" courses we take in nursing school and NP school that you claim we have too much of in our curriculum? Well a few of those research and theory courses we take focus on just that: RESEARCH. The course I took in graduate school called "Research" was a graduate level course that focused on things involving grading research, creating research plans, and disseminating evidence based findings into practice (among several other things). That is what my courses in nursing theory and health promotion and disease prevention also taught..

Given your ability to judge the quality of studies as evidenced by this thread, you either weren't paying attention or should ask for your money back.

You don't think I see the limitations of these studies? Do you know how difficult it is to measure and control all the components you are asking for in a study like this? You care so much about this, how about you publish a study?

Well you brought up studies that were very poorly designed which quite obviously focused on very nebulous data points that could be taken in a vacuum to show equivalency, so I'm not sure that you actually are aware of the limitations. And I don't have to publish a study, because there have been good studies published already that I already mentioned. Those studies somehow managed to take into account those variables, so clearly it can be done (and has been more than once).

Nevertheless, I agree, the studies have their limitations (e.g., short follow up periods and lack of controls). Although outdated, there were well-publicized, well-conducted randomized trials conducted in the 1970s that proved the concept that an autonomous primary care APRN can deliver care comparable to that provided by a primary physician (Burlington Randomized Trial of the Nurse Practitioner, the St. John's Randomized Trial of the Family Practice Nurse).

Okay but what you're missing is those studies tracked things like blood pressure after being treated for HTN or fasting glucose after being treated for diabetes. When your only factor for equivalency is whether or not you can get a patient's blood pressure into normal limits, you can show that a janitor is equivalent to a physician. That information says nothing about the care. That you can't see that is why I'm saying you don't get research.

These studies may have made further proof of equivalence seem unnecessary, particularly since independent APRN practice in primary care and urgent care were widely implemented in many states and throughout the VA, where rigorous quality assessment has been applied since the 1990s.

No they don't, particularly because more extensive studies showed that there is only equivalence when NPs are allowed unlimited time to see patients, have smaller patient panels, have access to physician consults, etc. That's not equivalency.

But with increasing complexities in primary care, definitely its clear that more studies that measure more variables need to be done with further quality assessment measures in areas like the VA where independent practice is present and data like this can be tracked (VA still does this). With that said, to date, all the studies I've come across are reassuring and have not shown any significant differences in the measures like practice patterns, frequency of tests ordered, quality of life, mortality, etc. Of note, there is a policy paper Newhouse and colleague and studies by Naylor and Kurtzman that I suggest you look at since you're all about good evidence. The data from the former and the later papers were major and corroborate what I've been arguing regarding independent ARNP practice. In fact, these were the studies that the Institute of Medicine and RWJF used to back up their calls for NPs to practice at the top of their licenses and their claims that there is no practice differences between the two groups.

Then you are ignoring the numerous papers that show that NPs order way more tests and consult more frequently, which costs patients money and open them to unnecessary procedures. That's not a small matter.

The answer to the primary care shortage isn't to give lesser educated practitioners more independence and the responsibility of physicians who have upwards of 20 times the clinical training as well as significantly deeper basic science training. It's to recruit more physicians to primary care.

Now read carefully "Foxy". Having said everything I just said, I'm still for the team based approach in a majority of the areas of medicine. Obviously, an NP will not practice independently in specialty areas. Of note, no NP I have ever met is against working with or for physicians. I (and most nurses) have a ton of respect for doctors and know our place in matters of complicated medical issues that are outside our scope..Need I repeat that? Because this is the 2nd or 3rd time I said this to you. In areas where there is decreased access to primary care services or same day visits; or where physician collaboration is highly inconvenient or impossible; or in general where access to health care services may be limited; my stance (and the stance of many others [i.e., physicians, nurses, administrators, the public, and policy makers]) is, and will be - until data says otherwise - that NPs should absolutely be allowed to practice autonomously. We know our scope and when to refer. I'm so convinced of this that 21 other states (and counting) and D.C. are making this a reality.

I don't care how you plan to practice, as that is not the issue here. I have yet to tell you that you will try to practice autonomously, so stop trying to argue against that. That's called a straw man.

Next, NPs absolutely want independent practice in as many fields as possible. If they were all flocking to primary care, you think we'd see a dent in the shortage. But the NPs flock to the money too, and when they end up where they do, they want to "practice at the top of their licenses."

Your stance can be whatever you want. That doesn't make it right. If you seriously care about patients, I have no idea how you can advocate for lesser trained folks whose training pipeline is non-standardized and in many cases woefully inadequate. You have case after case of NPs failing to diagnose things a third year med student would catch. Yes, doctors miss things occasionally too. But that is not a legitimate reason to loose lesser-trained providers on the patient population (you may not actually think that way, but I've heard it before).

You mentioned that I "claimed equivalence, which goes against all the good evidence out there." Do you have data that negates any points I have made so far? Care to site anything?

All the best Dr. "Foxy".

Primary Care Outcomes in Patients Treated by Nurse Practitioners or Physicians
Evidence Brief: The Quality of Care Provided by Advanced Practice Nurses - VA Evidence-based Synthesis Program Evidence Briefs - NCBI Bookshelf

I've already alluded to a bunch of studies. I am on a bus on my way home from an FTX. Later tonight I can post some cites unless someone beats me to it.
 
All I want is better data. One hundred fresh NPs versus one hundred fresh physicians, no backup on the NP end, 10 year study duration, only objective outcome measures, analyzed by a third party with de-identified data. Kaiser could do it with new hires, it would be about the simplest and most straightforward data analysis ever performed. From there you could break down outcomes by patient population.
I'm beginning to wonder if FNP has pre written responses to everything that might be said of the NP profession.

FNP is clearly on a mission, and it isn't to help students become doctors.

Regardless, NP's will never be MD's.

You're right, NPs will not become MDs unless they go to medical school. That's not the point of my arguments.
 
You're right, NPs will not become MDs unless they go to medical school. That's not the point of my arguments.
I just want data that proves they're as safe as physicians. The easiest way would be a long term study against physicians. Either they will be able to do the job or they won't, that's what I want to see to prove safety of fresh NPs.
 
I'm beginning to wonder if FNP has pre written responses to everything that might be said of the NP profession.

FNP is clearly on a mission, and it isn't to help students become doctors.

Regardless, NP's will never be MD's.

"light at the end of the tunnel" just because I have intelligent responses, that are well thought out (more than you have offered so far), doesn't mean I have pre-written responses. It just shows that I am well informed about my profession and the industry. And I'm all for student's going into medical school. You think I wan't a NP operating on me if I need bypass surgery? I actually have a couple of friends that are in med school. They both are nurses that I've worked with before they wen't in and I'm very proud of them. And regarding your statement about me having an agenda - well you're right - I do have an agenda - to increase access and provide quality care for patients. NPs do that safely and effectively and I believe are benefiting society and providing a good service.
 
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