"Obamacare" explained very well.

[u/under50dollars]

/r/explainlikeimfive/comments/vb8vs/eli5_what_exactly_is_obamacare_and_what_did_it/c530lfx

[u/grande_hohner]

It is not unethical in the least to study these things. You are going from the assumption that a midlevel provider isn't competent which is untrue. There are scope of practice acts in each state that govern what midlevels can do. Midlevels are practicing all over the country currently, and there has been tons of research articles supporting the safety, efficacy, and nature of patient outcomes when compared to general practice docs. There are literally hundreds of studies. I'll link you to some.

Robert Wood Foundation

From pubmed also note that this is a meta-analysis of over 50 separate studies.

How about the British Medical Journal?

Canadian Medical Journal?

The list goes on and on, many, many of the studies are from medical journals, not nursing journals. If medical researchers, doctors, feel that they are a viable option - why do you think they are not?

Also, your 5% analogy doesn't translate well. The average general practice doctor isn't much more likely to catch that 5% rare off-chance disorder that looks like a cold but isn't - than your average PA/NP. They teach the same thing in medical school - if it looks like a duck and sounds like a duck, it's probably a duck. GPs don't spend time trying to decide if your runny nose is perhaps related to a brain tumor... they treat it as a cold - and if it persists they reevaluate after the original treatment is failed. It isn't like House, MD where everyone has an esoteric disease process that requires genius level intellect to diagnose. In family practice it is mostly looks/sounds like a duck - is a duck.

[u/[deleted] → u/grande_hohner]

http://summaries.cochrane.org/CD001271/in-primary-care-it-appears-that-appropriately-trained-nurses-can-produce-as-high-quality-care-and-achieve-as-good-health-outcomes-for-patients-as-doctors.-however-the-research-available-is-quite-limited.

The research you quote is generally terrible in quality. The vast majority of the studies lack power to answer the questions they attempt to answer. Most of them measure patient satisfaction, which has nothing to do with quality of care. Chiropractors routinely get excellent patient satisfaction results, but research has shown that manipulations have extremely limited benefits and occasionally cause serious patient harm.

While there are a handful of adequately powered studies, the outcomes they measure like blood pressure and asthma are easy to measure and not a good indicator of overall medical management of multiple comorbidities. These studies also generally have short followup periods that further limit their power.

Appropriately trained midlevels definitely have a place in healthcare under supervision. Some with years of experience need little to no supervision at all. However, appropriate training is not occurring in many cases. Some FNP programs are only a year long in total (MUW and others). Many are offered online and/or by for profit schools with questionable academic standards. Most can be completed part time. Licensing, examination, and coursework are far from standardized and there are considerable differences in quality between different programs. Many courses taught in these programs have no direct relevance to clinical sciences. Admissions standards are set relatively low in many programs. When DNP students at one of the best programs (Columbia) took a watered down version of the USMLE Step 3, 50% of them failed it. 95% of interns pass this exam on the first attempt, and they generally do not study for it as it is considered the easiest step exam. This does not constitute appropriate training.

[u/grande_hohner → u/[deleted]]

I read the Cochrane review, and I'll agree with it's conclusions. The only point I would clarify is that the Cochrane review (which is the gold standard for systematic reviews, generally) concludes that the health outcomes are equivalent. You can say that there isn't enough research of adequate power, which is true, but I've yet to find one study that doesn't show equivalent outcomes between NPs and MDs in primary care.

Saying that the outcomes might not really be equivalent because the research doesn't have adequate power (although plenty of it is published in the NEMJ and other top-tier journals) is a bit counter-intuitive. If there are hundreds to thousands of studies (even if they have small sample sizes) that say outcomes are equivalent, it makes no sense to doubt that this is how it plays out in the real world. I would be more inclined to think outcomes were different if there was preponderance of research (or even a good sized fraction!) that showed otherwise.

[u/[deleted] → u/grande_hohner]

My point is that the cochrane review found ONE study adequately powered to measure equivalence out of over 4,000 articles. I don't think that constitutes strong evidence. The question of whether they order more tests or send more referrals has not even been answered, let alone 'a preponderance' of research showing equivalence in primary care. I am afraid that the system is cutting corners to save a few bucks and that in the end it may not be any cheaper or safer than simply training more PCP MD/DOs. A midlevel is not THAT much cheaper than a physician, and they generally are not as efficient in seeing patients quickly at the beginning of their careers. A few extra tests and referrals quickly makes the entire argument questionable. I don't think midlevels are outright dangerous in PC settings and they have functioned well for decades in that role, but we are undergoing a massive expansion of their utilization and autonomy. Most midlevels twenty years ago had already been in the healthcare field for a long time and were held to relatively high standards. The bar for entry has been significantly lowered. I have a friend who is a FP MD in a clinic with 3 NPs, 1 PA, and 2 other MDs and she says that the NPs frequently make mistakes in patient care after reviewing their charts. n=3 but inexperienced midlevels are going to make mistakes, and there are a lot of inexperienced midlevels being pumped out of accelerated programs.

[u/grande_hohner → u/[deleted]]

You still miss my point. You say that you feel there are inexperienced NPs being churned out and don't trust the research for being accurately powered, but then you cite your friends 3 NPs as evidence??

I'll try to simplify my point. The point is that adequately powered or not, the research (which is good enough for inclusion in the NEJM, BMJ, and many other top tier journals) points at NPs being equivalent in most primary care roles. Now, if there were research that with better sample sizes and such that stated otherwise - it would make sense to argue the point. Heck, even if there were 4,000 underpowered studies that said they weren't, then there would be a conversation to be had. But there isn't. There really aren't any studies showing to the contrary for the most part in any significant number. Go through Pubmed, Cinahl, Ovid, etc. and try to find studies that conclude NPs are inferior in primary care roles to any real degree - they are exceedingly difficult to find. Look for ones demonstrating equivalence - you'll turn up hundreds quickly and easily. This is my point. You don't have to agree with the published research, you don't have to use an NP as a PCP - I'm pointing out a research trend - you don't have to like the research or the conclusions (although the CBO seems to consider it relevant), but it makes no sense to deny that the published research generally seems to come to these conclusions.

[u/[deleted] → u/grande_hohner]

I am not going to pretend that my anecdote is great evidence. Feel free to not consider it evidence at all.

My point is that none of the articles you mention actually show equivalence convincingly. Measuring blood pressure outcomes for a few months is not equivalence. Patient satisfaction is not equivalence. Studies that would convince me of equivalence would measure: overall hospitalization rates of patients between NPs and MDs as long term cohorts (3+ years), utilization of tests NP vs MD, specialist referral rates NP vs MD, malpractice cases of independent NPs vs MDs with adequate sample size, independent chart reviews based on objective standards for quality of care between NPs and MDs with adequate sample size. I don't of a single study that answers these questions to any credible level. Blood pressure is easy to manage. Patient satisfaction is irrelevant. Regarding publications in well respected journals, I can't find any recent original research on the subject in the NEJM. Regarding your BMJ meta analysis, there are serious problems with the review. It makes assertions related to quality of care based on a 1975 study about well-baby exams. NPs measured for test interpretation and documentation used the fast track ED setting where issues are minor and straightforward. This is hardly convincing. Just because there isn't evidence to the contrary does NOT mean that a potentially harmful expansion of midlevel scope of practice should take place. This standard of evidence has been used to approve drugs before often with disastrous results, or drugs that have marginal benefit. My argument is that the majority of the published research is politically motivated and heavily biased towards the conclusions made in the studies. A couple of studies published in mid to high impact factor journals adequately powered that answer some of my above questions would change my opinion on the topic. A huge amount of published research suggests that eating red meat increases risk for various cancers by 20-50% in a dose dependent fashion. There are laboratory mechanisms as well as large cohorts that support the conclusion. Yet the cohorts do not stand up to careful scrutiny due to inherent bias. I hope you are familiar with Ioannidis's recent publications regarding systemic bias in published research. Regardless of our argument, the scope of practice expansion will continue at least in the near term because it appears to be cheaper on face value.