YoYo: M.D.s Offer More Than Nurse Practitioners

The article (1) reports “studies that show equivalence in care between nurse practitioners and physicians are flawed.” I actually know this to be true as I have blogged here reviewing many of these studies. Why the yoyo reference? Well, this article (1) is a response to an article written in The Wall Street Journal (2) called The Doctor Won’t See You Now: Primary care is moving toward teams of health-care professionals that may not always include a physician; where they state:

A number of studies have suggested the quality of primary care provided by nurse practitioners is as good or better than care by doctors, with comparable outcomes at equivalent or lower costs.

So, the first this article (2) claims superiority of care by nurse practitioners (NPs) and the response article (1) says these studies are flawed. See the yoyo? So I emailed the author ([email protected]) for the references for this statement. This is the response: “The email account that you tried to reach does not exist.” Hmmmmmmm?? Suspicious no doubt. But I’ll admit that I am biased in my opinion as a former NP and now MD. I’ll acknowledge that my experience as such likely biases my view. So, what is one to do? Go to the research. Since I couldn’t obtain the references for the original article (2), I looked more closely at the research referenced in the response article (1). One of the article comments to the article (1):

the large review she refers to is the Cochrane Review. It was completed in 2018. Through a literature search, they identified 9354 studies that might be pertinent to the question, but only 18 were found to be adequately done. Of these, only 3 were in the US and pertain to the situation in the US (How NPs are trained and how they are integrated into the South African medical system is not pertinent to our discussion.) These three studies were 53, 21, and 20 years old.

            I know this systemic review (3). I’ve referenced it in blogs before (4). This review was actually an update from a 2005 (5) review by the same authors. Their conclusion:

this conclusion should be viewed with caution given that only one study was powered to assess equivalence of care, many studies had methodological limitations, and patient follow-up was generally 12 months or less.

            In support of the article written by Dr. Bernard, my previous blog reported: a 2014 literature review titled “Substitution of physicians by nurses in primary care: a systematic review and meta-analysis,”(6) states in it’s conclusion: “The available evidence continues to be limited by the quality of the research considered”……” “The slowly growing number of studies, assessing substitution of physicians by nurses is still substantially limited by methodological deficiencies.”(6) Another review (3,7) which is an update to an earlier review (5)  lists several outcome measures but lists the evidence as a certainty level of low to low-moderate and concludes: “The effects of nurse-led primary care on the amount of advice and information given to patients, and on whether guidelines are followed, are uncertain as the certainty of these findings is very low.”

You do the math. 

References:

  1. https://www.wsj.com/articles/m-d-s-offer-more-than-nurse-practitioners-11601068900?fbclid=IwAR1xPwzfT7CWO5p5AaL6vrIxyWt7XTQ3VfxhfdrjgykOfIS94P-WsF-WrLU
  2. https://www.wsj.com/articles/the-new-doctors-appointment-11599662314
  3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6367893/
  4. https://authenticmedicine.com/2019/05/keeping-my-former-profession-honest-a-refutation-of-aanp-position-statement-on-educational-effectiveness/
  5. Laurant M, Reeves D, Hermens R, Braspenning J, Grol R, Sibbald B. (2005). Substitution of doctors by nurses in primary care. Cochrane Database Syst Rev. 2005 Apr 18;(2):CD001271.https://pubmed.ncbi.nlm.nih.gov/15846614/
  1. Martínez-González et al. Substitution of physicians by nurses in primary care: a systematic review and meta-analysis. BMC Health Services Research 2014, 14:214 http://www.biomedcentral.com/1472-6963/14/214
  2. 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.

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