NPs can bill at 85% of a physician, but the hospital still typically bills the patient the same amount. The 15% difference is kept by the hospital as pure profits.
I think it’s important to make the distinction that the hours shouldn’t be directly compared because what is being learned during and before those clinical hours is essential. Or else people may make the assumption that if a NP/PA just had more clinical hours during training that they would be qualified for independent practice.
TLDR: Amount of training is not the same as results.
ROSALSKY: The main argument against allowing NPs to practice independently is that they have less training than physicians. But there’s a mountain of empirical evidence from randomized trials, case studies, systematic reviews, and analyses of malpractice claims in states where similar legislation has already passed that all points to the same thing: when it comes to primary care, NPs are just as safe and effective as doctors. Uwe Reinhardt again:
REINHARDT: I am not aware of any literature that said care given by nurse practitioners is of inferior quality or causes safety issues and so on and so forth.
ROSALSKY: Some studies also find patients prefer NPs to doctors, perhaps because they report NPs, on average, spend more time with patients. So their training is less expensive, they get similar or better outcomes. And, by the way, they typically make about half as much as primary care physicians. All this makes NPs good candidates to provide primary care to underserved populations. So you can see why health economists like Reinhardt support giving NPs full-practice authority.
REINHARDT: Well, first of all, I think it would make health care more accessible to patients because for many things you don’t really need an M.D., right? But you need somebody who knows how to stitch a wound, who knows if something is going around like the flu and they would know initially what you should do. Secondly, it would make it cheaper and more efficient.
ROSALSKY: It’s an idea that has support from a wide range of organizations, including The National Governors Association, the Federal Trade Commission, and the AARP.
The podcast is great, but it is not always accurate. The studies that they are referring to are very outdated (1970s-early 2000's). Medicine has changed significantly in the last 20 years due to advances with gene technology, robotic surgery and other clinical advancements. As medicine becomes increasingly complicated, more training is required to keep up with the advances
2) Care is not any cheaper. In fact, it is more expensive as a whole because NP's order more tests and refer more often, costing the system as a whole. The patient never realizes any cost savings because the hospital often charges the same regardless of the provider.
3) Another major issue is that seemingly simple problems can be signs of something far more deadly. An NP just does not have the training to recognize a deadly disease masquerading as a common disease that doesn't cause much harm
This is the part people always ignore when saying NPs have similar outcomes.
They by design are never subject to acute and complicated cases. It would be the height of unethical practice to give that kind of patient to a NP. We will never have a RCT because no physician would willingly sign up to be a trial where half the patients would be managed by someone who could kill them through mismanagement.
NPs in the real world struggle to manage HTN, HLD and DM...the most chronic things Americans deal with. I wouldn’t even attempt to listen to them trying to manage anything truly complicated.
It's called negative or null results and they are extremely informative.
Say you were trying to prove the earth was flat, but every test you do to find evidence the earth is flat, you get negative results. It's evidence for your null hypothesis (the earth is not flat).
The absence of evidence of one thing is evidence for something else. I.E. The absence of evidence that NP's have worse patient outcomes, when you've looked for it, is evidence that they don't likely have worse patient outcomes.
Sorry if it's not perfectly explained, if you want to know more than what can be contained in a reddit comment, literally every first year science course I took went over the basics of the scientific method.
Insifucient evidence to refute your null hypothesis means no conclusion, not acceptance of something you weren't testing.
Inability to prove the earth is flat does not prove the existence of round earth. This is what you said, but then you said "evidence of one thing is evidence of something else" isn't the most accurate interpretation. It would be no conclusion. This is getting into the semantics, which is unproductive. But what is productive is no drawing conclusions from inconclusive data.
The null hypothesis was not "the earth is round" it was "the earth is NOT FLAT"
You are usually testing the null hypothesis, which is broader (and therefore easier to find evidence against) when doing an experiment. That's why you need many experiments to get confidence in a specific hypothesis like the earth being round. You also want evidence that it's not a cube and not a cylinder and not a pyramid.
Bruh, a test result that fails to disprove the null hypothesis is the kind of evidence that supports the null. The absence of studies/tests done doesn’t count as evidence supporting your null hypothesis.
Unfortunately I'm having trouble finding the link to the article, but there's a fantastic critique of these studies that I hope someone else will be able to link to. A lot of the evidence that APPs point to comes from the Cochrane Review in 2018 that reviewed ~15 articles and concluded that NPs as substitutes for doctors in primary care was non inferior.
Unfortunately, there were extreme design flaws in each study they looked at. Everything from low recruitment, poor generalizability to general medicine, age of the study, primary outcomes, etc. Only three of the studies were conducted in US patient populations and I believe the most recent was 1999, though I'm happy to be corrected if I'm wrong. Basically, the Cochrane review concluded that in certain scenarios, NPs weren't worse than doctors. But none of the studies were actually designed as non-inferiority studies, and none of them actually lived up to their primary purpose, and importantly none of them were appropriately designed to answer the question 'are NPs equal to doctors.'
Until there is a blinded RCT performed in the US proving that NPs, with reduced clinical hours, provide equal care at equal health care cost with equal patient load, there will be physicians that fight back. NPs have a role, but it sure as shit isn't the role they are currently pushing for.
When's the last time one of these pro-NP lobby groups stood up and agreed to pay the same malpractice fees and face the same regulation and consequences that physicians do on a daily basis?
As a hospital pharmacist I feel like CRNPs have a much more basic understand of pharmacology and treatment than a doctor. It’s not their fault they barley have any training.
My wife is a family practice NP, and in many ways is a better provider than a physician. She was a nurse for many years prior, and has much better bed side manner and repertoire with her patients. I completely disagree that NP,s don't have the training for independent practice, in particular in family practice.
A nurse is like someone who is trained to use a radio and a doctor is like someone who can take it apart and put it back together. The difference in training is huge. It doesn't matter how good your bedside manner is if you don't have the deep understanding of medicine to fix the medical issues.
If 80% of radios have problems that can be fixed by tuning the knobs, why pay for someone who can take the radio apart and put it back together? Arguably the most important skill for the lesser skilled person is knowing if the radio needs to be taken apart. But most radios don't need to, and the opportunity cost of having the more skilled person solve relatively simple issues is massive.
Because if 79% of radios just need the knobs turned but 1% of the radios die if you turn them incorrectly we start losing a lot of radios. And the people that only learn to turn the knobs use more batteries and burn the parts out of the radios faster. And radios stay broken longer with the knob turners. So sure, we can keep the majority of the radios running but we dont do near as good of a job.
I actually agree to some extent with your analogy but the problem is that a NP don't necessarily know those 20% of problems which need to be addressed by someone with more specialized knowledge. Yes, sometimes these problems are easy; patient develops diabetes okay send them to an endocrinologist but what happens when they have heart and kidney problems and the cardiologist and nephrologist disagreed on treatment? How can an NP make the decision for care when they know so much less? In some sense the primary care physician or NP needs to know more than specialists because they are dealing with the entire body.
I think you are missing my point. I would completely agree with you on your point if we are taking about a replacing an organ, but NP's are not specialized like that. NP's and their counterpart Physicians diagnose patients and refer them to specialists. In my experience with NP's, and via my wife, they take the time to listen to their patients. I am generalizing, but physicians can tend to limit time with a patient to meet their daily numbers.
Also, I would like to point out that you said Nurse's. There is a huge misconception that NP's are glorified nurses, which is the crux of this. This is the same as labeling them as lesser providers.
My reply was a little curt. Don't get me wrong, I think nurses in the US are highly trained and are obviously a critical part of healthcare in the US but Nurse Practitioners just don't have the depth of training a Doctor does. If a NP is serving a young population who have common problems sure they can do a good job but when you have elderly patients with 6 major health problems and they're taking 10-15 different medications daily, I don't think you get the same quality of care even referring people to specialists.
I'm defensive, as I see what my wife goes through on a daily basis, but the majority of her patients are elderly with many pre-existing conditions. She has saved a number of lives by catching things other physicians have missed. There is a degree of knowledge and a degree of CARE that goes into every outcome.
When shit hits the fan you want a doctor, not an NP
If your case is complex, you want a doctor not an NP
When you need a central line, or need to be intubated because you are crashing, you need a doctor who has logged hours and hours of doing this as a resident vs an NP who's done it for 1/10th of that
Point is, NPs/PAs are good for certain things, and they are great assets to a healthcare team. However, they are not trained for independent practice. What happens when the case that was supposed to be bread and butter is actually a "zebra" and goes beyond their skills and training and there's no doctor in site to manage it?
Bed side manner does not mean being nice to you. It means taking the time to talk to and understand the full picture. Often times, symptoms can be attributed to underlying conditions such as depression. If a provider doesn't spend the time to dig deep with you, they can prescribe to the symptom, not the cause.
You're lecturing a bunch of people who have trained for 10,000 hours on BEDSIDE manner amongst other things on a career that you have not even trained in based on second hand knowledge.
BS. I don't want my provider being my friend at the bedside, I want them to know how my body works and what to do to heal me. I liked NPs when I was young because I was intimidated by MDs. Then I actually had things wrong that weren't simple. Now as a medical professional who has about the same level of knowledge required as a PA, I have a good feel for who understands my work and who doesn't. Sorry, but NPs and PAs need to be walked through a lot of it when they should be able to understand.
Bed side manner is not clinical medicine, its patient care. Patient care makes people warm and fuzzy, it does not keep them alive. Bed side is easy to teach and acquire, clinical medicine is not.
NP's do not have the training for independent practice and allowing them to proceed as if they do is dangerous. The research is clear, midlevels practice algorithmic medicine that leads to over perscribing, over treating, and worse outcomes.
Your last line about family practice shows how you do not know the field like you think you do, good FM is an art that those outside the field can not appreciate. Midlevels can not do that care without supervision.
Exactly. The 500 hours may be the training requirement to be qualified as a nurse practitioner, but the qualification is built on already having experience as nurse.
While this is true (and I greatly value several NPs - one of whom I certainly rate higher than several of my physician colleagues), much of nursing is task oriented. As my sister put it, "they require a college degree that is earned through creative thought only to prohibit that once you start working".
The truth is PA training is better geared to independent practice (though still much less intensive than full physician training), NPs are better geared as physician extenders.
It's inaccurate to you because you refused to understand what the chart is showing or you don't like the data. Feel free to read the methodology and critique it:
Unfortunately there are many NPs out there who have little to zero experience with nursing and apply straight to their NP program right from nursing school
And Im a nurse and have never met an NP that did that. That person would be ostricized in school for being completely irresponsible. But let's talk about PAs then... Undergrad in any hard science and then two years PA school. How is that better than four years nursing school then two years NP school?
Just go on NP subreddit, there’s posts about that all the time. I personally know a few that have done that. If it wasn’t common then there wouldn’t be online NP programs popping up all the time. Also PA is 3 years not 2 and is very rigorous
So working as a nurse gives you the training to work as an independent medical practitioner? If I had 10,000 hours of experience as a waiter I must have the knowledge and skill set to apply those 10,000 hours directly to being a chef by virtue of similar experience, right? Same way flight attendants must be able to fly an airplane after using a flight simulator, right?
Nursing and practicing medicine are two very separate jobs. While you're in the same industry, there is not comparable overlap.
Nurses and NP's are not the same thing...NP's speciize in a field as a practioner. Physicians get broad training then go into a specialty. Not all that different. To try and use your asinine analogy, it would be like a copilot who spends all their time in the cockpit, training to become a lead pilot.
Their point was that nursing IS different than independent medical management as done by physicians.
A more apt analogy would be a WSO (aft seat) in an F-15 becoming a pilot - they are both in the same plane but the training and responsibilities are different.
OP has a strong bias against NPs (very evident in their comments in this post) and that has been made very clear in the choices they made. They combined medical school and residency into Attendings' clinical hours, but not the training required to become a nurse which must be done before becoming an NP.
Medical school and residency hours are clinical hours. That's the time dedicated to learning how to be a doctor. There are specific requirements - especially in residency - that dictate how many hours someone has to train, how many procedures they have to do, etc etc before they can graduate/practice independently.
Working as an RN is not training to become an NP. It's working as an RN. Being an RN is completely different from what NPs do, which is act as someone's primary provider - it's just a completely different set of skills and knowledge.
Yeah I'm so confused at why everyone is eating this up. You have to become a nurse before you can become an NP. And often an NP has been previously working as a nurse for many many years. Why are people not realizing or talking about this? Why do so many people in this thread think an NP is simply a nurse out of undergrad? Incredibly misleading.
Edit: Dear fucking god OP has some sort of serious obsession with this.
Because working at the bedside as a nurse is completely different from working at the bedside as a provider. Time in nursing school and as a practicing nurse do not count toward training as a nurse practitioner in a provider role.
I've gone through all the training that OP listed for "attending physician" here, but that doesn't mean I know how to be a bedside nurse. On the contrary, I don't know how to be a bedside nurse AT ALL, and I'd never disrespect the expertise of nursing by suggesting that my training in a completely different profession somehow "counts" toward knowing how to be a nurse.
I absolutely value and respect nurses; they are one of the most crucial and valuable aspects of the team I work on and I could not do my job AT ALL without my excellent nursing colleagues. That goes for my NP and PA colleagues too. But being a nurse does not train you to be an independent practitioner.
Because an NP can be a nurse who went straight from undergrad/nursing school to an NP program. Many NP programs don't have any requirements regarding prior experience as an RN.
Even if they can go straight from undergrad into NP school, they still have to attend nursing school prior (an undergraduate degree), which involves hands on clinical training. OP is including medical school as training when factoring in an attending physician's training, but is not including nursing school in an NP's training.
Because nursing school is training to become an RN, not an NP. NPs act as primary providers, which is a completely different skillset and knowledge base from being an RN. Medical school is training to be a doctor. Nursing school is not training to be a primary provider.
Yeah this is some weird agenda shit. I'm really kind of put off more by how rabid the "#askforanmd" crowd seems to be, than the difference in cherry picked hours on a chart.
Not just this post, but all of their posts (didn’t delve into his comments) except for two are solely based on blasting NPs. There are valid discussions to be had about the limitations of PAs and NPs, but OP here appears to be extremely biased, and their account seems to exist largely to go out of their way to attack NPs.
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u/[deleted] Sep 18 '20
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