Forget the Beef. Knock off Meat Substitute is Worse Than No Beef (An Exposé on the AANP Position Statement: Quality of Nurse Practitioner Practice)

It’s bad enough not having any beef on one’s burger, but trying to pass off a knock off substitute as the real thing is sinful. Trying to pass of poor quality, outdated studies, or studies lacking power as quality evidence is analogous to trying to pass off beef substitute as the real thing.  Take for example the AANP Position Statement: Quality of Nurse Practitioner Practice:

            I am not anti-NP, but rather pro-truth in publication. I was a Psych NP for 8 years prior to becoming an MD. I have found much dishonesty, bias writing, and downright hostile and emotional anti-MD literature and social media on the topic. A recent item being floated around social media ridiculously stated something to the effect that there is no evidence that shows NP’s can’t do MD’s jobs so therefore the assumption we are supposed to draw is that as such, they can. This is biased rhetoric. Take the aforementioned position statement. The first sentence states: “The bodyof literature supports the position that NPs provide care that is safe, effective patient-entered, timely, efficient, equitable and evidenced based.” Ok, so now the leap to be made in the position statement is that this equates to physician level care. Faulty assumption. This position statement states “…………, NP care is comparable in quality to that of their physician colleagues. ”In other words, we are supposed to infer that the literature supports this directly. But enough pontification, let’s look at the first of the evidence listed:

Avorn J, Everitt DE, Baker MW. The Neglected Medical History and Therapeutic Choices for Abdominal Pain: A Nationwide Study of 799 Physicians and Nurses. Arch Intern Med. 1991;151(4):694–698. doi:10.1001/archinte.1991.00400040048011

What do you see right off the bat? (1) 1991? An 28 year old study. Outdated. (2) Archives of Internal Medicine Journal. Seems like a good journal. (3) 799 study subjects, lacks power and thus both internal validity and generalizability. Draw your own conclusion at this point. The position statement reports that this study:

            The position statement reported that “adequate history taking resulted in identifying………….” The position statement also concluded that “compared to NPs, physicians were more likely to prescribe without seeking relevant history” asking the reader to infer that the physicians history taking was poor, inadequate, and ineffective, that the physician missed key items and that the history taking of NPs was superior. Maybe the difference in history approach highlights the difference in professions. Also, the study asked participants to report on hypothetical situation – talk about Hawthorne effect and bias. There was also almost twice as many physicians in the study than NPs. This is skewed and leads to sample bias. We’re asked to compare apples and oranges in this study and the position statement’s conclusion. The bias displayed is that what NPs did was good and what the MDs did was bad. Maybe apples do it the way apples do it, and oranges do it the way oranges do it. 

The study reported: “Nearly half of all physicians indicated that a prescription would be the single most effective therapy; 65% recommended a histamine antagonist.” This statement is a play on statistics. There were twice as many physicians in the study. One could state “nearly half of all physicians, or a number similar to the number of NP participants………” The study also reports “These findings raise concerns about the adequacy of basic history taking in this setting.”This was based on the reported data that “the nurse sample asked an average of 2.6 questions vs 1.6 for physicians.” Thus, the conclusion of the study is based on 1 additional question asked by NPs than MDs. 

This study at the time may have had merits, but 28 years later, research and methodology has advanced making this study not of the best quality to infer such a premise of the position statement that NPs can do MDs jobs. 

Robert Duprey MD

Robert P. Duprey Jr studied medicine as a 2nd career medical student who went to medical school in his 40’s after honorable discharge and ‘retirement’ from 25 years in the US Military (USCG & US Army). He was a registered nurse (RN) with specialty training as a psychiatric RN in the US Army for 15 years. During this time he also became a Master’s level psychotherapist in 2002. While on US Army active duty he also became a Psychiatric Nurse Practitioner while working full time in 2011. He served as a Psych NP on active duty, to include a combat tour in Iraq, until his ‘retirement’ in 2014 and moved to Philippines with his 3 children. At this time he started medical school overseas at Oceania University of Medicine based out of Samoa accredited by Philippine Accrediting Association of Schools, Colleges and Universities (PAASCU). He continued to work as a Psych NP throughout medical school to support his children and to not have to take out loans for medical school tuition. Originally from Rhode Island, he completed medical school clerkship rotations throughout the USA with a graduation in May 2019 earning the esteemed credential of MD. He has successfully completed USMLE Steps 1, 2CS, and 2CK. He will take Step 3 this September as he applies for Psychiatry Residency. Having been and RN, NP and now MD, he is a believer of Physician led multidisciplinary healthcare teams 

  3 comments for “Forget the Beef. Knock off Meat Substitute is Worse Than No Beef (An Exposé on the AANP Position Statement: Quality of Nurse Practitioner Practice)

  1. Pat
    June 4, 2019 at 1:20 pm

    From what I can’t tell by reading a lot of NP activist stories and comments, there are a hell of a lot of NP’s that want to play doctor without going to all the trouble to actually become one.

    All you need is a white coat and a fun chain pharmacy outlet.

  2. Steve O'
    June 4, 2019 at 9:56 am

    When inflation hits an economy but is masked to conceal its existence, there are supply shortages and compromises in quality.
    During the housing bubble and slump around 2007 (and the second dip is coming soon) there was a shortage of housing for buyers at first. Nobody wanted to sell their “800k” house at its new value of $500K.
    Next, quality went down. You could still afford a $400K house-but in a bad neighborhood, old and decrepit.
    In medicine, the beanheads call it “quality harvesting.” Why get a CT surgeon if this general surgeons do chests and heads?
    Wait until EMT’s get prescription privileges.

  3. KD
    June 4, 2019 at 9:26 am

    I would be interested in your personal experience regarding a comparison of your knowledge base when you graduated from NP school vs medical school. It’s very difficult to know what you don’t know until you know you don’t know. You know? NPs are an excellent addition to the team and I certainly know several who are sharp and capable of working without direct supervision on most of the common complaints, but to be independently practicing without physician consult readily available? Admittedly, I had some trepidation going into solo practice directly out of residency, so I can’t imagine an NP feeling confident to do the same. What was your experience?

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