Trust Them, Even if They’re Not Doctors

Trust Them, Even if They’re Not Doctors

A twitter thread of mine commenting on the ability of nurse practitioners (NPs) to perform most of the functions primary care physicians (PCMDs) can perform generated a significant amount of heat.

For context, this lively discussion began after a post I wrote criticizing Dr. Mark Lopitan’s op-ed in The Intelligencer on Pennsylvania SB 25, which would allow NPs to practice unsupervised after three years or 3,600 hours of collaboration with an MD.

Because it’s difficult to address the thoughtful objections of many physicians’ advocates 280 characters at a time, I would like to take the opportunity to fully outline the case for the competence of NPs here on rent check.

Before responding to individual arguments against independent practice, let me restate my thesis as clearly as possible: Based on the evidence available, there is no reason to prohibit NPs from practicing independently up to their full education–especially after an extensive collaboration period with a physician. Now, let’s dive into the objections.

First, a number of physicians objected to the idea that NPs can perform most of the tasks we expect doctors to perform:

 

Let’s be clear, under Pennsylvania law, there are a wide range of procedures that NPs cannot perform that MDs can, such as surgery. Indeed, the list of procedures NPs may perform is relatively modest, and includes:

  • ordering (though not necessarily interpreting, depending on the collaboration agreement) diagnostic tests;
  • Completing admission and discharge summaries;
  • Diagnosing patients;
  • Making various referrals;
  • Developing and implementing treatment plans.

You will notice that surgery, the application of anesthesia, and other more complicated procedures do not make the list. While there is a reasonable debate to be had over whether or not NPs should be allowed to perform more complicated procedures, the question at hand is whether or not NPs can perform these procedures unsupervised, and even then only after 3,600 hours of collaboration with a physician.

Next is the question of supervision and quality of care:

These are factual questions. Ignoring all of the anecdata (it’s a big country–there are horror stories about bad practitioners, both doctors and non-MDs everywhere), what does the research say? One 2017 study of the nation’s SOP laws found that SOP restrictions do not improve the quality of care.

Another study found that in some cases:

Beneficiaries attributed to PCNPs had lower hospital admissions, readmissions, inappropriate emergency department use, and low-value imaging for low back pain. Beneficiaries attributed to PCMDs were more likely than those attributed to PCNPs to receive chronic disease management and cancer screenings. Quality of care for beneficiaries jointly attributed to both clinicians generally scored in the middle of the PCNP and PCMD attributed beneficiaries with the exception of cancer screening.

So, it is true that there are some instances in which MDs are better suited than NPs to provide certain treatments. But an argument against granting independent practice for NPs this is not. To put it simply, there is no serious evidence to suggest that NPs, operating to the extent of their training, provide lower-quality care across the board than MDs do, especially in the primary care context.

If you don’t believe the research, a survey of MDs found that:

Regarding NP scope-of-practice, most PCMDs (77 percent) agree that PCNPs should practice to the full extent of their education and training…

When asked how increasing the number of NPs would affect physician employment, 57 percent of PCMDs said their income would decrease, and three-quarters agreed they could be replaced by PCNPs.

What is indisputable, however is that NPs (and other non-MD providers) are able to provide care much more cheaply than MDs. It is also the case that healthcare utilization and the number of patients seen increases with expanded scope-of-practice, particularly in the case of primary care. Care quality and regular check-ups increase with more liberal SOP regulations, while the number of emergency room visits declines. The supply of NPs also increases when SOP is expanded, especially in rural areas with a severe primary care physician shortage.

The debate then veered off course into some strange arguments about the curriculum of nursing versus medical school:

Now, it is true that the curriculum for NPs is different from that for MDs. But that’s not necessarily bad–while the most recent crop of MDs is better trained than their predecessors, they are using less of their education in their actual practice (in fairness, the study cited refers to family physicians). This is evidence that while NPs can perform more routine medical procedures, MDs can specialize in the more advanced procedures that NPs cannot perform.

Ultimately this argument is semantic. If you believe the term “medical training” refers exclusively to those who have gone to medical school, then no, NPs do not have medical training and neither do (most) military medics, RNs, PAs, EMTs or other professionals we trust to deliver some form of healthcare. But a more expansive, common sense definition of “medical training” would include those professions. And, it must be added that this distinction, as it has been used by MDs in this debate, is more used to diminish the credentials of their non-MD peers rather than to inform the debate.

Finally, we have some arguments related to whether or not supervision requirements restrict choice:

 

These arguments are downright strange. SOP restrictions, by definition, restrict the ability of NPs to perform medical procedures they may want to perform (or do so unsupervised). And these restrictions in turn restrict the ability of patients to go to a practitioner. This has been confirmed by a 2017 study researching a previous scope-of-practice expansion in Pennsylvania. It found a significant increase in the number of retail clinics in the state compared to neighboring New Jersey and Maryland.

Much of the MD-led opposition to expanded SOP seems to be driven more by self-interest (and ego) than well-founded beliefs about patient safety or quality of care. The debate over independent practice for NPs looks like a near-perfect example of public choice theory in action–concentrated interests fighting tooth-and-nail to preserve a system that passes costs onto the rest of us.

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By |2019-04-19T07:38:20-07:00April 19th, 2019|Blog, Occupational Licensing|