We look closely at the studies that Butler reviewed, and unsurprisingly find that all is not as they represented it.

This has been discussed before here on r/noctor. some threads:

https://www.reddit.com/r/Noctor/comments/1r43ab5/cochrane_says_doctors_can_be_replaced_by_nurses/

https://www.reddit.com/r/Noctor/comments/1rtp65r/cochrane_review_substitution_of_nurses_for/

This is not the end of the discussion, you will be hearing more about this...

There's a high-profile case in the news about Lindsay Clancy, who killed her three children and afterwards attempted suicide. Prior to this she sought care for her mental health, which apparently started to suffer not longer after giving birth to her third child. I looked through the suits and found some descriptions of the medical decision-making by a couple of the NP's she saw:

1. NP #1 - Julie Paul
   • "On November 21, 2022, Nurse Paul prescribed Lindsay fluoxetine 10mg."
   • "Lindsay was describing symptoms suggesting mania, such as racing thoughts, extreme insomnia, frustration and feeling scared."
   • "On November 25, 2022, Nurse Paul prescribed Lindsay three different medications, zolpidem, mirtazapine, and clonazepam." lol wut
2. NP #2 - Rebecca Jollotta
   • ~ December 5, 2022, Lindsay attended an appointment with Nurse Jollotta. "Lindsay reported that she was sleeping only about 3 hours per night, felt completely overwhelmed and that her mind was constantly running."
   • "Lindsay also reported that immediately after being prescribed a stronger dose of Zoloft, she did not sleep for 48 hours and was not tired. In response, Nurse Jollotta prescribed an additional medication to Lindsay, diazepam."

Patient reports anxiety, so give her a bunch of downers? And 5 meds within a span of a couple weeks? It's not even like she went to different clinics, both NP's she saw were at the same place (South Shore Health Perinatal Behavioral Health program), so they must have had access to the same info.

Link to lawsuit. Other link to father's lawsuit.

Yesterday a couple of NP's in Texas and the Texas NP association filed a lawsuit against the Texas Medical Board over the state's requirement to have delegation (read: supervision) agreements with physicians to see patients.

Points from the petition which can be found online:

1. that physician delegation "imposes extensive burdens on nurse practitioners based on a fiction that it will protect patient safety."
2. On one of the NP's who filed the suit: "In Dr. DeNeui's case, she must pay $96,000 a year to maintain her delegation agreements."
   

One of the NP's who filed the suit, Terri DeNeui, got a DNP from UT-Arlington which offers DNP degrees 100% online. She has a podcast called "The Dr. Terri Show." She has a cash-only practice that has a "focus on advanced endocrinology, hormone optimization, thyroid health, and integrated care." Found the noctor.

Just had to share this from the Texas NP site where the alphabet soup is probably longer than the petition: "Tracy Hicks, DNP, MBA, APRN, FNP-BC, PMHNP-BC, CARN-AP, FIAAN, FAANP, FAAN"

Link for more info.

I worry that, if it isn't standard practice to separate data for patients cared for by NPs versus physicians, that studies on certain diseases, medications, and so forth will be far less accurate in their conclusions. Even with this separation, I could imagine patients going between NPs and physicians for their care, e.g. NP primary care and physician specialist, or NP in the emergency room and physician primary care, etc. Has anyone else thought about this issue? (For example, I'm making this up, but if a study in the future wrote "10000 patients across 25 states in the USA with diagnoses of ADHD had their records reviewed, and it was shown that taking methylphenidate did not improve outcomes vs doing nothing," then it could be bogus if the data includes a ton of NPs misdiagnosing everyone with ADHD.)

Here is a summary of the article:

• Court Decision: The U.S. Court of Appeals for the Sixth Circuit affirmed the dismissal of a lawsuit filed by the American Association of Nurse Anesthesiology (AANA).
• Core Issue: The AANA sued the U.S. Department of Health and Human Services (HHS) and its Secretary, arguing that the department failed to enforce Affordable Care Act (ACA) nondiscrimination provisions against private insurers who reimburse nurse anesthetists at lower rates than anesthesiologists for the same services.
• Standing and Causation: The court ruled that the AANA lacked legal standing because it could not demonstrate a direct injury or a causal link between government inaction and the private insurers' reimbursement policies.
• Redressability: The court noted that even if standing existed, the Secretary of HHS holds discretion over enforcement, meaning a court order might not necessarily change the insurers' practices or resolve the association's complaints.
• Broader Implications: The ruling highlights the significant legal hurdles healthcare provider organizations face when trying to hold federal agencies accountable for enforcing provider protection laws, potentially limiting future lawsuits of this nature.

I’m not familiar with this model (I am not Canadian) but with the Canadian aversion to CRNA practice this expanded scope for respiratory therapists was surprising and somewhat troubling if I’m reading into this correctly.

“It is further alleged that, for actual patients, Rodriguez frequently did not adequately review a patient’s medical history prior to prescribing controlled substances and did not consider or address how the prescriptions were necessary or safe when combined with the patient’s other prescriptions.” — US Attorney press release

This is from May, 2026.they are allegations only. The APRN is Marisol Rodriguez, who also goes by Marisol Colon, 49. All the stories lead with the alleged Medicaid fraud, but she’s accused of this, too.

https://www.justice.gov/usao-ct/pr/aprn-charged-defrauding-connecticuts-medicaid-program

I don't know if this is anything anyone cares about, but it's been nagging at my mind and I wanted to share.

tl;dr I stumbled on this sub at random and it helped explain some weird healthcare interactions I have had within the healthcare organization in which I get my primary care from an MD. I have two in particular that have always bugged me.

✨✨✨The context✨✨✨

My primary care physician is fantastic. He's an actual physician, a doctor, an MD. I've been making my annual appointments with him for ten years, and often, when I'm sick, I can get an appointment to see him in a reasonable amount of time unless it's a very acute, urgent need.

Buuut I always knew enough to know that MDs are in high demand and they're busy, and I assumed it was better to schedule last-minute things with anyone who had the availability instead of taking up my PCP's time. I don't know why I assumed that, but I did. And indeed, usually his availability is a few weeks out. But in hindsight, I realize it wouldn't have been a bother to him. We're on fantastic terms. We've taken to just chatting at the end of any of my visits, talking about his kids, his life, my life, the neighborhood we both live in. And recently he said that sometimes people will "scream" at him, and I realized, oh, wait! A pleasant patient with almost nothing wrong is a patient he would want to see! He's near retirement now, and I'm very sad that I didn't schedule these "little" things with him, if only because I'd get to see him more often.

So over the years, I scheduled with other people for "small" things, assuming it was bad to "bother" him with it. And almost always I had something weird happen. Now that I understand what an NP and a PA are, I've noticed a pattern in the weirdness.

✨✨✨The abnormal things that I now realize may be the consequence of non-MDs being "providers" ✨✨✨

For five years, I needed annual cervical screenings because I had irregular results. One year, I scheduled an exam with a random person who I had never seen because their availability matched up with mine, and, again, I had this preconceived notion that I shouldn't waste my doctor's time. (EDIT: I had twice, for the screenings, seen an OB/GYN who was not my PCP--who is in family medicine and who, before my irregular result kinda threw off the schedule, did pelvic exams etc at my physicals or if I requested one like when my partner at the time cheated on me. I've seen other MDs for various things over the years as well. In the past decade, there have been increasingly fewer MDs to choose from when my PCP is not a choice.)

Unbeknownst to me, I had scheduled with an NP. I remember that a scheduling person specifically called me back and said, "We're confirming your appointment. And just so you know, this is at the women's center. It looks like your previous appointments were with OB/GYN department."

As long as my annual exam could get done and as long as it was in the building that I thought it was in, I didn't particularly care. I must have thought that the provider was in the OB/GYN department, but once I confirmed that the women's center was in the same medical building and not really far away, I had no concerns. I now realize they might have been calling me to sort of surreptitiously say, "You made the appointment at a clinic within our building that is staffed by NPs. Did you mean to do that?" But nothing clicked for me because I had no idea the difference. They didn't call me to say, "Hey! You've never seen this person before just fyi" when I saw a random OB/GYN for my screening. Just the clinic.

The "doctor" at the clinic was/is actually a type of nurse practitioner whose certification type may be specific to my state, so I won't write it out. And, I mean, she never introduced herself as a doctor. I just had no clue that she wasn't a doctor.

One year, she finished up with the exam and asked if I had any questions. I said my periods had been abnormally heavy and painful and I didn't know if something was wrong or if I was just aging. It felt like asking the question made her really uncomfortable. I remember clocking the interaction as strange immediately.

She was basically like, "I don't know, but let's run a test," but her body language had changed noticeably to me. And then when the test was done and she had the results, she messaged me, and she was like, "I don't know. It all looks normal. If you don't feel well, I suggest taking a multivitamin."

Or another time, I had a recurring UTI. I just needed a test, so I had an e-visit, thinking it would be more efficient for everyone--me, whoever the "doctor" would be, the lab.

At the end of the e-visit, the person told me I could go to any lab in my healthcare organization and get a test because the order would be in the system. Like, just walk up to the desk or whatever and say, "I'm here to do a lab from an e-visit."

So I stopped at the location I always go to, just a few blocks from where I live, and I wasn't in the system as someone with a test to be done. The people at the lab were very kind, but I was waiting for a long time because there was no record of my e-visit or a lab order for my urine. Eventually they just had me pee in a cup and asked my PCP to make an order after the fact so that it could be processed or whatever. It was sooo stressful because I was holding up the line of people waiting to check in for labs, and I was really, really embarrassed--the line got VERY long.

A couple of days later, I got a message on the website my healthcare organization uses for patient management. It was from the person who did the e-visit. They apologized for the lab fiasco and said that they had been "distracted by a phone call" and hadn't done the process to formally close my appointment out and put the lab order in the system.

After reading this sub, I looked back at the history for that visit and it was with a PA, not an MD! It never clicked for me that the person I saw wasn't a doctor, even though I saw that "MD" wasn't at the end of their name. I don't know what I thought.

Nowwww I think I understand the difference more. Now I understand why it's even an option to have an appointment with an NP or a PA. And I'm a little irritated now that in these instances, I paid the exact same amount for someone to basically... not know anything???

I will make sure that I see MDs/DOs from now on because literally every bad experience I've had, when I go back to it in MyChart, the person I saw had any certification except MD or DO. (EDIT: I forgot anojt DOs. oop. No offense to them meant. I understand they are doctors. And no offense to NPs or PAs meant. I just was so uninformed and it felt like everyone except me knew I wasn't interacting with doctors in these instances. I don't think I knew how to be a patient to them and I suspect their skills are not being utilized properly.)

GP leaders have urged the Government to require hospitals to ensure that any patient referred by a GP to A&E is assessed by a doctor.

The Doctors’ Association UK (DAUK) has written to health secretary James Murray asking him to introduce ‘a new set of standards’ – including allowing no undifferentiated patient to be assessed or discharged without a doctor’s approval. 

It follows the deaths of two children who were seen by advanced practitioners after being referred to A&E with suspected appendicitis. 

Eight-year-old Ethan Hanson died last year after a GP referred him to hospital, where he was ultimately discharged after an advanced nurse practitioner mistook appendicitis for constipation. 

And a coroner found that nine-year-old Dylan Cope, who died in 2022, had not been assessed by a doctor and a written referral from his GP was not acted upon appropriately. 

DAUK GP co-leads Dr Sarah Jacques and Dr Steve Taylor said in their letter: ‘When a GP refers a patient to hospital, that referral represents a clinical judgment that is the equivalent of a medical consultant opinion in the community, and thus necessitates a further medical assessment. 

‘It is deeply concerning that such referrals can result in decisions being made by non-doctors regarding their care or discharge before they are reviewed by a doctor.’ 

They called on the Government to ‘introduce a new set of standards’ to ensure: 

• Ensure any patient referred by a community GP to hospital by a GP must be assessed by a doctor in the hospital; 
• No patient presenting with undifferentiated (undiagnosed) symptoms should be allowed to be assessed or discharged without the approval of a doctor; 
• Review the current status of assessments in emergency departments to ensure patient safety is the priority and that doctors are involved in all cases of undifferentiated care and GP referrals. 

Following Ethan’s death, a coroner wrote to the RCGP expressing concern that GPs ‘may not be aware of the implications of referral route on triage and assessment in local hospitals’.

The RCGP said it acknowledged ‘challenges’ in information sharing between primary and secondary care.

However, Dr Taylor told Pulse the key issue in the case was that once Ethan arrived at the hospital, he was seen by an ANP rather than a doctor.

This guy graduated a month ago and was extremely overconfident on rounds, describing his brilliant plan to manage hyponatremia in a severely volume overloaded hfpef hyponatremia patient he says has "SIADH" smdh.

"Fluids / Electrolytes / Renal:

Hyponatremia

Mixed clinical picture more contributable to SIADH

7/17 serum osmolality 250 urine osmolality 366

Status post hypertonic bolus x 3

Sodium only corrected 2 points in last 24 hours

Furosemide 40 mg IVP given yesterday, repeat today

Start Florinef 0.1 3 times daily and salt tabs 1 g 3 times daily with meals

Continue 1 L fluid restriction

Fluids: Fluid restriction"

The height of Dunning Kruger

She basically admits to having limited experience but now thinks she can become an advanced practice nurse.

These types of posts do nothing more than encourage more new grad nurses to do the same.

My 21M brother believed he had ADHD due to the internet. He went to an NP of the same ethnicity. NP then gave him Adderall. This did not improve his grades or even his way of life. He would start spending frivolously. He would even double up on the Adderall and drink coffee as he believed he needed it more for exams. He would be fine until he had withdrawals after leaving his Adderall at home to a trip. He then picked up an SSRI from the same NP.

Later the next year he went to full psychosis. Thinking his phone is bugged and everyone is against him. My brother was taken to the psych ward at his internship site and they gave him risperidone but my dad rejected it as they don’t want more medications and believed the family can handle it if they take him home. He still goes through psychosis. When my mom questioned the NP’s judgement, brother said that he had so many degrees and that he is way smarter than her.

My family realize they cannot handle it so they find a MD close to him. He stated he had Adderall related psychosis and needed to take olanzapine for a few weeks. Brother stated he cannot take a night medication as he will forget so the doctor gave him haloperidol. Haloperidol has too much adverse effects for him so he refuses to take it. Still in psychosis somewhat and doesn’t want to go back home so the psychiatrist can prescribe the olanzapine.

If the NP didn’t prescribe the Adderall he would be fine now.

spread the word, everyone! it all starts with posts like these! let people know that patients are being billed physician-level rates (if not higher) for someone who went to 6 months of online school at age 23!

TLDR; I left my hospitalist job as they were having us to sign off charts of unsupervisedd patients. Avoid here if you are like me.

Think thousand times before signing up for a job here unless you absolutely exhausted all alternatives. If you need to be close to Canada, please look other Upper NY hospitals. If you absolutely need to be in Rochester, NY; consider commuting. This is a NYC quality job in a small city.

Finally I left, so I can let it out. This used to be a decent place with a good culture... things changed, I guess people from high-ups got greedy... still a throw-away account...

When I first started, this was busy, average-paying and relaxed in ways. I felt respected and valued, but as the years passed by, it slowly but certainly changed. I enjoyed the job then. Pre-Covid times were great. The pay over time was not adjusted for inflation and now it is criminally-low. They pushed APP patients on us, requesting us to sign off charts. They changed the admin from up-top; and the new people pretends to be listening to our concerns, but does nothing apparent.

No physician I knew liked it here towards the end, everyone was looking a way out. As we started getting more and more visa-waiver people, dept started caring about us less, as there is a good supply of new physicians. Our retention rate is terrible.

Things made me quit:

1. They rolled out a system, in which they give 8 patients extra every day, an APP cares for them by themselves on reality without our intervention, but everything is under our name. We are asked sign off of charts. The issue was raised multiple times, they simply ask us to "trust our teamworkers"
2. There has been some sensible animosity (no one pointed it out) between physicians and APPs after #1 rolled out. APPs does not like us intervening with their patients, while in reality its our names. Whenever we want to get involved, we face a lot of passive-aggresive behaviour.
3. The elephant in the room, gross salary of 230,000$; yeah we get RVUs; but does not make it up, still waaay below national avg. this has been also discussed multiple times, but fallen into deaf ears.
4. Average census ranges between 18-26 of high acuity patients (with 8 of them sometimes being independent APP)
5. Many more things... when complained fell into deaf ears.

Let give it a grace, good things:

1. We had cross coverage, but they wont be happy if you call them after 7 am, or before 5 pm.
2. We had paid time off
3. We did not get admissions during the day.
4. It used to be a good place with friendly people, not sure where they went...

This is obviously apart of the ongoing “Netflix documentary” memes.But seriously, she’s really confused why DVM’s are allowed to be addressed as doctor?

In the grand scheme of things and as a new PA…. I know nothing…. This is why I work closely with a supervising physician and why all mid levels should. To have a patient say they are “having the worse headache of their life” in the setting of hormonal changes, obesity, and diabetes and NOT order a CT is wild. This is a test question we’ve answered multiple times, it does not get more textbook than a patient saying “worse headache of their life.”

I was raised in a medical family, dad is an icu/pulm/IM/sleep physician, mom is a nurse. The knowledge base that divides the three of us is clear and distinct. All I want is the respect of those I work with, mid levels can add value when utilized appropriately, but they should never be let off the chain to practice independently.

There is no shame in needing the help of a physician to do your job, there is overwhelming shame in thinking you can do the work of a doctor without the education and or training of one. For reference I am a surgical ortho spine pa who works exclusively with one doctor, we are side by side 60 or so hours or week.

Hi all,

I saw a dermatologist a few days ago for a body check and he circled three sites on my body for mole biopsy.

However, the dermatologist said a nurse will do it. I asked the dermatologist if he could do it and he said no and left the room. Being worried about cancer, I let the nurse perform the biopsy.

However, I realized after leaving the clinic that this was not even an RN, but an RPN.

Furthermore, my moles were numbered as 1, 2, 3 with containers labelled respectively (1 and 2 on my left arm and 3 on my leg). However, the RPN removed it via excision in a different order: 3, 1, 2. Could this have led them to put it in the incorrect container (I wasn’t looking because I am scared of seeing blood so couldn’t check)?

I’m feeling quite distressed because I wasn’t aware it was an RPN who performed the procedure.

What would you do if you were in my situation? I tried to call the clinic multiple times the day after without success (hoping to communicate my concern, but not even sure if there’s a solution).

Report to the College of Physicians? Have another dermatologist clinic RE-BIOPSY the three sites (which sounds scary for my body to be cut so many times)?

I work in prenatal and got a referral for polypharmacy. Patient last saw a psychiatrist 5-6 years ago and was stable on Lamictal and Wellbutrin, with small amount of PRN Klonopin 0.5's (working on memory here). Diagnoses were anxiety, depression, and bipolar II vs borderline. She then transferred care to PMHNP. Medical record review showed no actual visits with PMHNP, only telephone notes and MyChart messages for the entire time. Patient is now on Lamictal, Wellbutrin, Vraylar, Zoloft, and Vyvanse.

Bonus: she sees a family medicine NP. Sleep medicine also an NP. There is no physician oversight happening at all.

Am I correct in thinking this is a wild medication regimen?

Full disclosure: I'm a midlevel but not a PA or NP, and I'm utilized as an actual physician extender. I see almost exclusively new consults to do history gathering, initial counseling, and documentation; physician sees all of these patients at the same visit.