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mid-level creep: current status in canada


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Hello all,

Read a few **DELETED** posts about mid-level creep in the states and how its a pretty big turf war down there, esp with nurse anesthetists coming up. 

I know the whole NP creep has become a problem in BC, but at the same time there are plenty of NP's here in Ontario and I'm not getting the same doom and gloom feeling from the medical community here about it. No clue about PA or nurse anesthetists though. 

Was wondering what predictions everyone had regarding this becoming a problem in Canada? 

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4 hours ago, hanoori said:

I know the whole NP creep has become a problem in BC

Citation needed.

In general the system is fundamentally different in Canada vs US. Who knows what the future holds but in my experience across three provinces, including BC, NPs support MDs and vice versa and fill very much needed gaps in care.

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I'm in Ontario in a major city. At the hospital across various specialties, I've only seen PAs and NPs play a supportive role and they seemed to prefer to do so (they enjoyed their regular schedule, benefits, etc.).

In the community, I think NPs in particular (haven't seen PAs) are very slowly creeping. Some of it is our own doing. For instance, I know of one family physician who basically doesn't see patients and just employs NPs. Another I know has been able to significantly increase his roster size by pawning off some to his in-clinic NP. They bill a lot, but it's very unethical, if you ask me. I've also seen patients from rougher parts of town go to community clinics where an NP acts as their GP. Even in my own suburb in a nice area, I once booked a virtual walk-in clinic appointment, and the secretary told me the doctor would call me. After the phone call, I looked the "doctor" up, and she was an NP working full-time in a walk-in clinic. The reviews of the clinic all referred to her as "doctor."

The rest of what I'll say is speculation, but I think we're naive to think this won't continue in Canada. Yes, our healthcare system is different compared to the U.S., but the government is always looking for ways to reduce healthcare spending. This applies especially to the Ford government. Western cultural trends seem to also be creating fertile ground for a new healthcare system. For one, some patients think that they can direct their own healthcare vs. what they family physician can do. These patients will happily pay for chiropractors, B12 injections, naturopaths, med spas, etc. At the more extreme end, our society is trending towards tribal and dogmatic thinking (likely because of political and socioeconomic instability). Such thinking is leading to a devaluing of science and modern medicine. So, I think such trends are resulting in patients having an appetite for more of a "free market" healthcare, and mid-level creep could exploit this.

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I've heard from a few people now that the BC government is quite motivated to train and hire nurse anesthetists in the province... Still in the planning phases as the UBC anesthesiologists don't really want to train them but its likely coming soon once they work out that problem...

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12 hours ago, bearded frog said:

Citation needed.

In general the system is fundamentally different in Canada vs US. Who knows what the future holds but in my experience across three provinces, including BC, NPs support MDs and vice versa and fill very much needed gaps in care.

Honestly wish I could find that article. To be honest, it wasn't the best article but it mentioned that BC just finds it cheaper to employ NPs than fam docs and how in the US NPs usually have a ROS to work rurally, but many as soon as that ROS is done work independently (wish I had a citation for that too). 

8 hours ago, Redpill said:

I've heard from a few people now that the BC government is quite motivated to train and hire nurse anesthetists in the province... Still in the planning phases as the UBC anesthesiologists don't really want to train them but its likely coming soon once they work out that problem...

Anyone in the forums in anesthesia want to comment on what theyve heard?

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A lot of it has been in the works for a long time I'd say. Here's my take on it:

- the # of MD spots has not increased much for many years, same with residency, so no matter how you view it, there's always a "doctor shortage".

- government come up with some half **** ideas about this "doctor shortage", like announcing they want to open up a new medical school somewhere 3 weeks before an election.

- "doctor shortage" becomes legitimate excuse to get more NP/PA and what not.

The way I see it, primary care value-add on is easily eroded. The services rendered by FMD are often substitutional and difficult for patients to see "value added". Yes preventive care helps down the road but that's not how consumer (aka voters) thinks. Voters prefer a pound of cure than an ounce of prevention. Voters want grandiosity in vision but impotence in delivery. Voters go #yolo. They'd rather think the ICU intensivist putting in ECMO in somebody is adding more value than FMD telling that person wearing a mask or stop smoking lol.

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There are older FM docs more than happy to employ NPs to increase their bottom line and make money. It slowly makes things worse for the younger generations.

In BC, the recently introduced salaried primary care contracts pay NPs more per patient than MDs, and then to double the insult - NPs generally will have much less complex patients, and are allowed to simply say "not in my scope" and defer to an MD. Ultimately if it takes off, you'll have MDs getting more and more disproportionately complex patients. This would still be a long ways away though - and the easy solution is not to succmumb to hiring them. The big issue with this is: Clinic owners don't really care. An MD or an NP, both will still pay 25-30% overhead and pad your bottom line, so if for some reason NP training skyrockets and more seats open up...well, it will be interesting. Where the govt will get the funding for all of it, hard to say, but the pie has to be split so many ways.

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24 minutes ago, JohnGrisham said:

Where the govt will get the funding for all of it, hard to say, but the pie has to be split so many ways.

I think we both know that answer to that question.

NPs have a use in very limited scopes in my opinion. The two main ones I see are:

1) Follow-up for hospitalized surgical patients (since care by an NP is much better than the generally subpar/inexistant follow-ups these patients usually get from their surgeon, which is something research at my center has proven).

2) Primary care in communities too small to warrant an MD.

Otherwise, they're more expensive than MDs in the long run and see fewer, less complex patients. What a fantastic deal!

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1 hour ago, JohnGrisham said:

There are older FM docs more than happy to employ NPs to increase their bottom line and make money. It slowly makes things worse for the younger generations.

In BC, the recently introduced salaried primary care contracts pay NPs more per patient than MDs, and then to double the insult - NPs generally will have much less complex patients, and are allowed to simply say "not in my scope" and defer to an MD. Ultimately if it takes off, you'll have MDs getting more and more disproportionately complex patients. This would still be a long ways away though - and the easy solution is not to succmumb to hiring them. The big issue with this is: Clinic owners don't really care. An MD or an NP, both will still pay 25-30% overhead and pad your bottom line, so if for some reason NP training skyrockets and more seats open up...well, it will be interesting. Where the govt will get the funding for all of it, hard to say, but the pie has to be split so many ways.

I don't know how this is allowed. I thought you can only bill for services that you personally do/patients that you see. 

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My personal thoughts, as I have also been following closely the advent of the NP explosion down south.

- the ones I work with are helpful in a specialty clinic followup setting. I personally would prefer that this care be delivered by GP-oncologists, however, their care has been well received and they are respected integrated professionals in the care team. Why is this care not being provided by underemployed specialists? Financial, and no desire to have this less desirable area of practice (eg survivorship) as a sole point of oncology consultant practice

- the US NP mill scam with sub-standard training for independent practice is quite alarming. By the time regulators recognize that this is a serious society problem, the horses will be long out of the barn

- I do support limited NP use with adequate supervision in focused scopes of practice. However scope creep is absolutely a thing

- Further anecdote from a Canadian friend recently training a Canadian NP student, is that it is quite remarkable how little physiology and medicine fundamentals that individual knew. There was a significant effort on both their part and the student’s part to study and learn material which forms the basis of medical school. Much like a clinical clerk, but non-standardized and certainly still to have knowledge gaps.

- MDs are expensive, and governments absolutely like to cheap out. The BC experience is worrisome to me, as it shows that regulators are not taking steps in keeping with incentivizing high quality care and access to MD care. It actively disincentives MDs to enter primary care, and incentivizes substandard NP primary care.

- This is the first time I am learning of possible Canadian CRNA equivalents. This is worrisome given the anecdotal stories and data starting to be published from the US. I see this as a very attractive option for our governments to pursue.

- My observations and readings from down south have lead me to form the opinions that independent NPs would cost the system (and patients) more in the long run with inappropriate diagnoses, inappropriate workups and increased use of specialist consults and expensive or invasive diagnostic tests that otherwise could be avoided. This is undesirable in a publicly funded system, and BC should be admonished with their primary care NPs. I would be really curious to see their internal data on secondary resource use there.

 

Ultimately and especially with macroeconomic factors beholding our country such as post-COVID inflation/possible stagflation, I see MD incomes dropping, and governments looking to save on ever-escalating care costs by further increasing NP use. I foresee that a portion of latest cohort of ICU, emerge, and acute care nurses that are quitting due to atrocious covid environments and burnout will find this career move attractive, and might accelerate some of this move. It will take significant advocacy from MD groups to combat this, however nursing unions are strong, and we simply do not have the awareness of the US pitfalls here in Canada, as the now quite common sentiment shared by US trainees and residents. There will be job competition from NP spots that will take over some specialty roles, and while this might be cost efficient, it is still difficult for me to say whether this still is appropriate care for patients, and will be hard to keep in narrow-scoped roles.

In the long term, I see increased scopes for NPs, CRNAs, PAs, relatively unavoidable in Canada. I do see quality of practice and incomes dropping for MDs, which is rather unfortunate, but moreso out of already cash-strapped publicly funded systems that are unwilling to keep pay levels at inflation-matched historical averages (this won’t be specific to MDs, but this is what I anticipate). This somewhat overlaps with the physician incomes thread, but it is interrelated I think. 

I do not know what the solution or remedy is, or if there is even one. Maybe I am a bit cynical or pessimistic, but lately there is a fair amount to be pessimistic about (and don’t get me started about covid in Alberta!)

</endrant>

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2 hours ago, offmychestplease said:

There are soo many 12-16 month online NP degree mills in the US that are accredited in Canada. RN's can do this on the side while even till working in Canada. Such an insult to the 10-15 year process for physicians when someone can become an NP this way and reap all the rewards ...

You are right, there is a newish NP in one of the local clinics, that did a US NP degree. Though i think hers was half in-person at least. 

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51 minutes ago, ChemPetE said:

My personal thoughts, as I have also been following closely the advent of the NP explosion down south.

- the ones I work with are helpful in a specialty clinic followup setting. I personally would prefer that this care be delivered by GP-oncologists, however, their care has been well received and they are respected integrated professionals in the care team. Why is this care not being provided by underemployed specialists? Financial, and no desire to have this less desirable area of practice (eg survivorship) as a sole point of oncology consultant practice

- the US NP mill scam with sub-standard training for independent practice is quite alarming. By the time regulators recognize that this is a serious society problem, the horses will be long out of the barn

- I do support limited NP use with adequate supervision in focused scopes of practice. However scope creep is absolutely a thing

- Further anecdote from a Canadian friend recently training a Canadian NP student, is that it is quite remarkable how little physiology and medicine fundamentals that individual knew. There was a significant effort on both their part and the student’s part to study and learn material which forms the basis of medical school. Much like a clinical clerk, but non-standardized and certainly still to have knowledge gaps.

- MDs are expensive, and governments absolutely like to cheap out. The BC experience is worrisome to me, as it shows that regulators are not taking steps in keeping with incentivizing high quality care and access to MD care. It actively disincentives MDs to enter primary care, and incentivizes substandard NP primary care.

- This is the first time I am learning of possible Canadian CRNA equivalents. This is worrisome given the anecdotal stories and data starting to be published from the US. I see this as a very attractive option for our governments to pursue.

- My observations and readings from down south have lead me to form the opinions that independent NPs would cost the system (and patients) more in the long run with inappropriate diagnoses, inappropriate workups and increased use of specialist consults and expensive or invasive diagnostic tests that otherwise could be avoided. This is undesirable in a publicly funded system, and BC should be admonished with their primary care NPs. I would be really curious to see their internal data on secondary resource use there.

 

Ultimately and especially with macroeconomic factors beholding our country such as post-COVID inflation/possible stagflation, I see MD incomes dropping, and governments looking to save on ever-escalating care costs by further increasing NP use. I foresee that a portion of latest cohort of ICU, emerge, and acute care nurses that are quitting due to atrocious covid environments and burnout will find this career move attractive, and might accelerate some of this move. It will take significant advocacy from MD groups to combat this, however nursing unions are strong, and we simply do not have the awareness of the US pitfalls here in Canada, as the now quite common sentiment shared by US trainees and residents. There will be job competition from NP spots that will take over some specialty roles, and while this might be cost efficient, it is still difficult for me to say whether this still is appropriate care for patients, and will be hard to keep in narrow-scoped roles.

In the long term, I see increased scopes for NPs, CRNAs, PAs, relatively unavoidable in Canada. I do see quality of practice and incomes dropping for MDs, which is rather unfortunate, but moreso out of already cash-strapped publicly funded systems that are unwilling to keep pay levels at inflation-matched historical averages (this won’t be specific to MDs, but this is what I anticipate). This somewhat overlaps with the physician incomes thread, but it is interrelated I think. 

I do not know what the solution or remedy is, or if there is even one. Maybe I am a bit cynical or pessimistic, but lately there is a fair amount to be pessimistic about (and don’t get me started about covid in Alberta!)

</endrant>

Agree across the board. NPs are great in specialty clinics and focused practice styles - a good one working in the same setting after a few years, often can function as a competent PGY1/PGY2 WITHIN that scope. A surgical NP managing day to day ward issues is a good example of this. The issue is when the NPs start to deviate, or come across cases that do not fit the patterns or things they have seen - fundamentals are greatly lacking. This is not an insult, it is simply factual - nursing is a different skillset then medicine, and nursing school is very very different than medical school. A NP masters is not a satisfactory alternate to medical school, yet alone a 2-3 year Family Medicine residency on top of medical school with respect to primary care practitioners.  Yet, here we are, where there are NPs in some jurisdictions, being the sole provider of care for many people without MD access, even in big cities. Not just rural/urban divide no longer. 

One of the main gripes I have, is that within the physician realm - many of our colleagues are very individualistic. Example: many former preceptors clearly abuse the fee for service system, without regard for the system as a whole. Effectively "the system will be eaten away by mid-levels down the line, so i should get what I can from it now until things change". This thought process effectively further pushes the system towards what we should be trying to mitigate and re-direct.  Virtual billing codes has drawn out a fair number of these individuals - i secretly hope the gov't used this as a trojan horse to crack down on some of them.   And my own rambling is an example of another issue: we are quick to "eat our own" and criticize each other.  Nursing unions are unified, often, and raise all tides within their ranks - while shaming and putting down the other HCPs like MDs.

Similar to the air-conditioning in heat-waves analogy. Yes, everyone should get air-conditioners, but often these devices(at least old technology), are actually further playing a role in perpetuating the root-cause.

 

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I think it will happen here as well. Inevitably as health care costs continue to rise and technology gets better and better, people will start to realize that some work that doctors currently do, does not need to be done by doctors. We joke about how the ABCs of emerg has become: 1. assess from the doorway 2. back away slowly 3. CT, but this and the rise of cover your ass medicine has led to much of medicine becoming simply algorithmic. You don't really need to understand the medicine as long as you know how to follow your guidelines and over order investigations so you don't get sued if something goes wrong. 

Private equity firms have already started to realize this in the US and have consequently started replacing doctors with NPs. If we have to face fundamental facts, the issue is we don't adequately track outcomes in medicine as they do in major surgeries. There is no "evidence" to show, physician run practices provide better outcomes compared with NP run practices. In the lack of evidence, whichever is cheaper will come out the winner. 

What needs to happen to primary care and anesthesia is similar to what happened between CABG vs PCI in the 1990s and 2000s. The advent of PCI forced a series of trials to demonstrate which aspects of coronary disease was best treated with medical management vs PCI vs CABG and we now generally have our answer. CABG initially lost more and more ground throughout the 2000s until eventually the evidence came out in favour of CABG and the pendulum swung in reverse and settled about half way. CABG certainly lost ground, but PCI also did not gain as much ground as they would have if the research wasn't done. This is what I believe needs to and will happen in medicine. In my opinion, there is no doubt that NPs will gain ground in the US and Canada and simple advocacy is not going to cut it. There is also no doubt that some aspects of medicine can be done by NPs in order to cut costs. However, until you have some evidence to back up your claims, you won't be able to convince the public of the necessity of physician training. 

 

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Besides the length and difficulty of training differences which are worlds apart that have been mentioned in this thread no one has mentioned the difficulty of becoming a physician vs NP in Canada. You have people here doing multiple degrees, re-writing the MCAT several times, applying to medical school many times (in fact average is 2-3) just to enter medical school at 24 (median age in Canada) beating out literally thousand of applicants VS someone who can easily enter an undergrad nursing program from high school or become an RN from literal community colleges and then do an online NP degree from the US in 12 months. It's not just insulting to the amount and difficulty of training of physicians vs NP's but the reason that physicians enjoy the monetary benefits is because of the very difficulty of barrier of entry....I am genuinely curious how do NP's think this right? I guess they don't care about these differences/sacrifices and everyone is out for themselves out there...sad

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The system may also go the NHS route. I read a stat somewhere that >40% of surgery interns in UK are FMGs from middle east, India, etc etc. They pay them few pence and work them like an a**. One consultant from UK said he could work here as a PA and make more money than a consultant in UK haha.

In case anyone is curious, the starting salary for resident doctor there is 28000 pounds. Maybe not poverty level, but if you live in an expensive city like London, I guess it's close enough.

https://www.imgconnect.co.uk/news/2021/04/nhs-doctors-pay-scales-in-the-uk-explained/59

As a consultant your maximum salary is around 110K pounds. Even if say you double it with overtime, on call, etc, and make 220K pounds, that's only 380K CAD. I am sure most specialist here can beat that easily.

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5 minutes ago, offmychestplease said:

Besides the length and difficulty of training differences which are worlds apart that have been mentioned in this thread no one has mentioned the difficulty of becoming a physician vs NP in Canada. You have people here doing multiple degrees, re-writing the MCAT several times, applying to medical school many times (in fact average is 2-3) just to enter medical school at 24 (median age in Canada) beating out literally thousand of applicants VS someone who can easily enter an undergrad nursing program from high school or become an RN from literal community colleges and then do an online NP degree from the US in 12 months. It's not just insulting to the amount and difficulty of training of physicians vs NP's but the reason that physicians enjoy the monetary benefits is because of the very difficulty of barrier of entry....I am genuinely curious how do NP's think this right? I guess they don't care about these differences/sacrifices and everyone is out for themselves out there...sad

I have to say though, as a profession, we need a realist mentality. Anyone's value in society is only as important as their usefulness to others at the current moment. I think if a NP is able to provide the exact same care as a physician in a given role, then that physician should be doing something more advanced. I just don't believe that physicians "deserve" anything just because they put in more time training. 

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8 minutes ago, offmychestplease said:

Besides the length and difficulty of training differences which are worlds apart that have been mentioned in this thread no one has mentioned the difficulty of becoming a physician vs NP in Canada. You have people here doing multiple degrees, re-writing the MCAT several times, applying to medical school many times (in fact average is 2-3) just to enter medical school at 24 (median age in Canada) beating out literally thousand of applicants VS someone who can easily enter an undergrad nursing program from high school or become an RN from literal community colleges and then do an online NP degree from the US in 12 months. It's not just insulting to the amount and difficulty of training of physicians vs NP's but the reason that physicians enjoy the monetary benefits is because of the very difficulty of barrier of entry....I am genuinely curious how do NP's think this right? I guess they don't care about these differences/sacrifices and everyone is out for themselves out there...sad

In my mind, the sacrifice/high barrier of entry shouldn’t matter. There is something to be said for the high opportunity cost of training, and the self selection of those who do apply to med tend to be very driven and capable people. But if I was an NP I could give a crap about the ‘sacrifice’. What should matter most are patient outcomes, and incentivizing and designing systems that achieve quality care for patients. The whole mcat and multiple degree rigmarole is very inefficient. No one cares about that other than mds, and they’re probably right not to IMO. Bottom line to me is the thorough medical training.

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1 minute ago, Edict said:

I have to say though, as a profession, we need a realist mentality. Anyone's value in society is only as important as their usefulness to others at the current moment. I think if a NP is able to provide the exact same care as a physician in a given role, then that physician should be doing something more advanced. I just don't believe that physicians "deserve" anything just because they put in more time training. 

How do you define exact same care? NPs in the US have been shown to order more expensive diagnostic imaging, more inappropriate antibiotics, and opioid medication. Patients get seen, issues get addressed. But is it the same to the patient at the same cost to the system? The BC NPs as mentioned above are being paid higher rates per patient than the family docs for less complicated cases. 

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4 minutes ago, ChemPetE said:

How do you define exact same care? NPs in the US have been shown to order more expensive diagnostic imaging, more inappropriate antibiotics, and opioid medication. Patients get seen, issues get addressed. But is it the same to the patient at the same cost to the system? The BC NPs as mentioned above are being paid higher rates per patient than the family docs for less complicated cases. 

I think that claim if backed up by solid evidence would be important, but until we get those studies, people will continue to debate this and entrench themselves. One important question on a hospital/government's mind is, will the cost savings of using NPs outweigh the costs of any more expensive imaging/inappropriate antibiotics etc. I think if we really get to that point, as physicians we should demand evidence before allowing NP scope creep. 

At the end of the day, the system is worried about its own bottom line, so i'm not sure how it works in BC, but in the US NPs cost less which is why they are being used. 

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8 minutes ago, Edict said:

I think that claim if backed up by solid evidence would be important, but until we get those studies, people will continue to debate this and entrench themselves. One important question on a hospital/government's mind is, will the cost savings of using NPs outweigh the costs of any more expensive imaging/inappropriate antibiotics etc. I think if we really get to that point, as physicians we should demand evidence before allowing NP scope creep. 

At the end of the day, the system is worried about its own bottom line, so i'm not sure how it works in BC, but in the US NPs cost less which is why they are being used. 

I can dig up the retrospective study list if you like. Book cost for sure they’re less. The problem is the downstream costs - you have to remember the US is incentivized for interventions; healthcare systems get reimbursed percentages of costs for tests, consults, etc. whereas here it just comes out of the healthcare budget. That’s why insurance companies and hospitals in the private system will try and maximize OR and surgeon efficiency for example, it’s a money maker. Here, ORs cost the system money and so the resources are rationed instead. The NPs ordering pan scans and inappropriate blood work will feedback money to their employers as well. What I’ve heard mentioned and have not seen is alleged Ontario data saying that they are more expensive.

Edit: directly copied from the bastion of the noctor sub forum, only as an example of the above

Resident teams are economically more efficient than MLP teams and have higher patient satisfaction. https://www.ncbi.nlm.nih.gov/m/pubmed/26217425/
Compared with dermatologists, PAs performed more skin biopsies per case of skin cancer diagnosed and diagnosed fewer melanomas in situ, suggesting that the diagnostic accuracy of PAs may be lower than that of dermatologists. https://www.ncbi.nlm.nih.gov/pubmed/29710082
Advanced practice clinicians are associated with more imaging services than PCPs for similar patients during E&M office visits. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1939374
Nonphysician clinicians were more likely to prescribe antibiotics than practicing physicians in outpatient settings, and resident physicians were less likely to prescribe antibiotics. https://www.ncbi.nlm.nih.gov/pubmed/15922696
The quality of referrals to an academic medical center was higher for physicians than for NPs and PAs regarding the clarity of the referral question, understanding of pathophysiology, and adequate prereferral evaluation and documentation. https://www.mayoclinicproceedings.org/article/S0025-6196(13)00732-5/abstract00732-5/abstract)
Further research is needed to understand the impact of differences in NP and PCP patient populations on provider prescribing, such as the higher number of prescriptions issued by NPs for beneficiaries in moderate and high comorbidity groups and the implications of the duration of prescriptions for clinical outcomes, patient-provider rapport, costs, and potential gaps in medication coverage. https://www.journalofnursingregulation.com/article/S2155-8256(17)30071-6/fulltext30071-6/fulltext)
Antibiotics were more frequently prescribed during visits involving NP/PA visits compared with physician-only visits, including overall visits (17% vs 12%, P < .0001) and acute respiratory infection visits (61% vs 54%, P < .001). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5047413/
NPs, relative to physicians, have taken an increasing role in prescribing psychotropic medications for Medicaid-insured youths. The quality of NP prescribing practices deserves further attention. https://www.ncbi.nlm.nih.gov/m/pubmed/29641238/
(CRNA) We found an increased risk of adverse disposition in cases where the anesthesia provider was a nonanesthesiology professional. https://www.ncbi.nlm.nih.gov/pubmed/22305625
NPs/PAs practicing in states with independent prescription authority were > 20 times more likely to overprescribe opioids than NPs/PAs in prescription-restricted states. https://pubmed.ncbi.nlm.nih.gov/32333312/
Both 30-day mortality rate and mortality rate after complications (failure-to-rescue) were lower when anesthesiologists directed anesthesia care. https://pubmed.ncbi.nlm.nih.gov/10861159/
Only 25% of all NPs in Oregon, an independent practice state, practiced in primary care settings. https://oregoncenterfornursing.org/wp-content/uploads/2020/03/2020_PrimaryCareWorkforceCrisis_Report_Web.pdf
96% of NPs had regular contact with pharmaceutical representatives. 48% stated that they were more likely to prescribe a drug that was highlighted during a lunch or dinner event. https://pubmed.ncbi.nlm.nih.gov/21291293/
85.02% of malpractice cases against NPs were due to diagnosis (41.46%), treatment (30.79%) and medication errors (12.77%). The malpractice cases due to diagnosing errors was further stratified into failure to diagnose (64.13%), delay to diagnose (27.29%), and misdiagnosis (7.59%). https://pubmed.ncbi.nlm.nih.gov/28734486/
Advanced practice clinicians and PCPs ordered imaging in 2.8% and 1.9% episodes of care, respectively. Advanced practice clinicians are associated with more imaging services than PCPs for similar patients during E&M office visits .While increased use of imaging appears modest for individual patients, this increase may have ramifications on care and overall costs at the population level. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1939374
APP visits had lower RVUs/visit (2.8 vs. 3.7) and lower patients/hour (1.1 vs. 2.2) compared to physician visits. Higher APP coverage (by 10%) at the ED‐day level was associated with lower patients/clinician hour by 0.12 (95% confidence interval [CI] = −0.15 to −0.10) and lower RVUs/clinician hour by 0.4 (95% CI = −0.5 to −0.3). Increasing APP staffing may not lower staffing costs. https://onlinelibrary.wiley.com/doi/full/10.1111/acem.14077
When caring for patients with DM, NPs were more likely to have consulted cardiologists (OR = 1.29, 95% CI = 1.21–1.37), endocrinologists (OR = 1.64, 95% CI = 1.48–1.82), and nephrologists (OR = 1.90, 95% CI = 1.67–2.17) and more likely to have prescribed PIMs (OR = 1.07, 95% CI = 1.01–1.12) https://onlinelibrary.wiley.com/doi/10.1111/jgs.13662
Ambulatory visits between 2006 and 2011 involving NPs and PAs more frequently resulted in an antibiotic prescription compared with physician-only visits (17% for visits involving NPs and PAs vs 12% for physician-only visits; P < .0001) https://academic.oup.com/ofid/article/3/3/ofw168/2593319
More claims naming PAs and APRNs were paid on behalf of the hospital/practice (38% and 32%, respectively) compared with physicians (8%, P < 0.001) and payment was more likely when APRNs were defendants (1.82, 1.09-3.03) https://pubmed.ncbi.nlm.nih.gov/32362078/
There was a 50.9% increase in the proportion of psychotropic medications prescribed by psychiatric NPs (from 5.9% to 8.8%) and a 28.6% proportional increase by non-psychiatric NPs (from 4.9% to 6.3%). By contrast, the proportion of psychotropic medications prescribed by psychiatrists and by non-psychiatric physicians declined (56.9%-53.0% and 32.3%-31.8%, respectively) https://pubmed.ncbi.nlm.nih.gov/29641238/
Most articles about the role of APRNs do not explicitly define the autonomy of the nurses, compare non-autonomous nurses with physicians, or evaluate nurse-direct protocol-driven care for patients with specific conditions. However, studies like these are often cited in support of the claim that APRNs practicing autonomously provide the same quality of primary care as medical doctors. https://pubmed.ncbi.nlm.nih.gov/27606392/
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Although evidence-based healthcare results in improved patient outcomes and reduced costs, nurses do not consistently implement evidence based best practices. https://pubmed.ncbi.nlm.nih.gov/22922750/

 

 

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48 minutes ago, Edict said:

I have to say though, as a profession, we need a realist mentality. Anyone's value in society is only as important as their usefulness to others at the current moment. I think if a NP is able to provide the exact same care as a physician in a given role, then that physician should be doing something more advanced. I just don't believe that physicians "deserve" anything just because they put in more time training. 

I agree but value is not something that can ever be easily measured. Proxies that are used are often deeply flawed, e.g. patient satisfaction scores in the ER.

The main danger is politics not matching reality. Physicians don't lobby well for themselves and public perception of nurses is usually relatively better.

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The fundamental differences of Canada vs the US is one important thing to consider: Canada is based on cost-control; US is based on maximizing profits.

If the govt could replace all FM MDs with NPs, and patients still get seen, and on average are still "just as happy", they could care less - many people right now already dont have family MDs. The system already has a non-negligible percentage of wasted fee-for-service visits by family docs and specialists alike.  "easy consults" to specialists, shouldn't exist as frequently as they do. Its frustrating to no end. The system is being overburdened by a lot of submitted crappy billing codes claimed.

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