Capgras Syndrome: The Effects of Nurse Practitioners Replacing Physicians

Capgras delusion is a psychiatric disorder in which a person holds a delusion that a friend, spouse, parent, or other close family member (or pet) has been replaced by an identical impostor (2). The same could sarcastically be said about nurse practitioners replacing physicians. The referenced article is by one of my favorite authors, but this blog is not about this article per se, but about how the reference to low quality studies often used as ‘proof’ to justify such a replacement. This is an item that I find disturbing the notion that often cited ‘evidence’ is misrepresented, misread, manipulated, and often low quality with many biases. The reason I blog about it is the pursuit of truth. My former profession is shooting themselves in the foot by often manipulating and misrepresenting data and research. I’ll say it again, one profession is not a substitute for another profession. The article references Laurant  M, van der Biezen  M, Wijers  N, Watananirun  K, Kontopantelis  E, van Vught  AJAH. Nurses as substitutes for doctors in primary care. Cochrane Database of Systematic Reviews 2018, Issue 7. Art. No.: CD001271. DOI: 10.1002/14651858.CD001271.pub3 (3) as an example of low quality evidence:

most of the studies that purport to show NP safety have been of low quality, often following healthy patients over very short time frames, with one often-cited study having a time frame of only two weeks. These studies were not appropriately designed to show whether nurse practitioners, especially practicing independently, can safely and effectively care for patients over the course of a lifetime in a primary care role (1).

            For the Cochrane review (3), the authors identified 18 randomized trials evaluating the impact of nurses working as substitutes for doctors. They report “uncertainty of the effects of nurse‐led care on process of care because the certainty of this evidence was assessed as very low (3).” The following was reported by the review:

1. Study findings suggest that care delivered by nurses, compared to care delivered by doctors, probably generates similar or better health outcomes for a broad range of patient conditions (low‐ or moderate‐certainty evidence).
2. Nurse‐led primary care may lead to slightly fewer deaths among certain groups of patients, compared to doctor‐led care. However, the results vary and it is possible that nurse‐led primary care makes little or no difference to the number of deaths (low‐certainty evidence).
3. Blood pressure outcomes are probably slightly improved in nurse‐led primary care. Other clinical or health status outcomes are probably similar (moderate‐certainty evidence).
4. Patient satisfaction is probably slightly higher in nurse‐led primary care (moderate‐certainty evidence). 
5. Quality of life may be slightly higher (low‐certainty evidence).
6. The effect of nurse‐led care on utilisation of care is mixed and depends on the type of outcome. Consultations are probably longer in nurse‐led primary care (moderate‐certainty evidence), and
7. numbers of attended return visits are slightly higher for nurses than for doctors (high‐certainty evidence). 
8. little or no difference between nurses and doctors in the number of prescriptions and attendance at accident and emergency units (high‐certainty evidence). 
9. There may be little or no difference in the number of tests and investigations, hospital referrals and hospital admissions between nurses and doctors (low‐certainty evidence).

So the next time when discussing this topic and someone says “the evidence……” be very suspect. I’ll just leave it right here for you to ponder. 

References:

1.  https://www.physicianspractice.com/patient-safety/effects-nurse-practitioners-replacing-physicians
2. https://en.wikipedia.org/wiki/Capgras_delusion
3. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001271.pub3/full

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