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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Robert Duprey MD

Robert is a 2nd career physician (MD); a combat Veteran with the US Army; a former psychiatric nurse practitioner; an independent researcher; a medical writer; and now having passed USMLE Steps 1, 2CK, 2CS, and 3, is a residency applicant.

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7 Responses

  1. Susan Payson, D.O. says:

    https://pubmed.ncbi.nlm.nih.gov/28234756/
    So a PA on facebook just told me that research shows that PA outcomes are the same quality as primary care physicians, and posted this article as proof. Comments???

  2. Bridget Reidy says:

    I’m in Canada where the concept is still kind of new, but like the US these days many don’t seem to learn on the job by working with physicians. What I can’t understand is BC pays them more! (At least until we got offered new contracts yesterday, but I haven’t figured out how much time in “panel work” and QI they expect and NPs have smaller panels which means we’ll be doing more uncompensated overtime, – so can’t really compare yet).

    Something to do with nursing unions, and governments traditionally blaming doctors for problems in the health system.

  3. Benjamin Van Raalte says:

    A court stenographer spends 40 hours a week for 10 years in court. If they take a 6-month course on legal theory does that qualify them to be a judge?
    If a factory assembler spends 20 years assembling cars and then takes a 6-month course on automotive design does that qualify him to be in automotive engineer?
    Of course not. Nursing hours are not the same as didactic medical school and residency.
    Furthermore in 90% of the cases they are going to be equivalent to physicians for simple cases. In 2020 Google is probably 90% equivalent to physicians. Therefore the nurse practitioner is the equal of Google. The problem is knowing what you don’t know and the arguments the nurse practitioners make clearly they don’t know what they don’t know.
    As a specialist rejecting 50% of the referrals from nurse practitioners as inappropriate whatever they say does not matter to me. I just know they give the patient whatever they want whether it’s tests referral to a specialist or medications. That leads to patient satisfaction but studies have shown patient satisfaction as poorly correlated with patient care. Patients want what they want even if it’s not the best for them.
    And let’s get to the root of what this is really about. It’s really about money. The argument of advancing equivalency is to argue they should be paid the same as physicians. Despite the fact their initial argument for nurse practitioners was to lower healthcare costs. What will ultimately happen though is not a raise in nursing payments but it decrease in physician payments. That will make the attractiveness of medical school plunge. The ironic thing may be in 30 years the best and the brightest will go to become a nurse practitioner it is the shorter route to be paid the same. Those that don’t qualify will go to medical school and the longer route with additional training to make up for deficiencies.

    • I have been on the record many times that this whole issue is a result of price-fixing. The doctors endorsed extenders as an adaptation to price-caps. Now we are in this mess. If ARNP’s and PA’s wish to independently care for patients then we need a free market and price distinction as to where paying customers wish to state their preferences. Additionally, the non physician health providers can also assume their true legal liabilities – cost and all. I suspect in short order the differences being argued will bear out. There is no doubt in my mind after practicing 26 years and watching the whole tragedy play out – US health care has gone down significantly and I correlate the steady decline with the onset of Medicare Price-Fixing of our services around 1997/8. We are all to blame for going along with the scheme.

    • PW says:

      Hospitals and facilities hire NPs precisely because they can pay them less than physicians. If they continue to insist on being paid the same as physicians, they will shoot themselves in the foot. Why would an institution or a patient pay the same for a less well trained practitioner?

      • Dr Susan Payson says:

        The answer is…the cost of healthcare the government cares about is its own cost in financing the trainings. Our costs more…school, internship, and residency. Theirs is school…nothing else. How much they charge once in practice isnt the government’s focus.

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