Nurse Practitioners
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Nurse practitioners (NPs) delivering emergency care without physician supervision or collaboration in the Veterans Health Administration (VHA) increase lengths of stay by 11% and raise 30-day preventable hospitalizations by 20% compared with emergency physicians, says a working paper published by the National Bureau of Economic Research.
That higher preventable hospitalization rate “may reflect two possibilities,” says the working paper, written by David Chan, MD, PhD, associate professor of health policy at Stanford University School of Medicine, and Yiqun Chen, PhD, assistant professor of economics at the University of Illinois at Chicago.
One is that “NPs have poorer decision-making over whom to admit to the hospital, resulting in underadmission of patients who should have been admitted and a net increase in return hospitalizations, despite NPs using longer lengths of stay to evaluate patients’ need for hospital admission.”
The other possibility is that “NPs produce lower quality of care conditional on admitting decisions, despite spending more resources on treating the patient (as measured by costs of the ED care). Both possibilities imply lower skill of NPs relative to physicians.”
Patients deserve greater clarity on who is a physician—and who isn’t
Overall, the study shows that NPs increase the cost of ED care by 7%, or about $66 per patient. Increasing the number of NPs on duty to decrease wait times raised total health care spending by 15%, or $238 per case—not including the cost of additional NP salaries. In all, assigning 25% of emergency cases to NPs results in net costs of $74 million annually for the VHA.“Increasing the number of NPs on duty decreases wait times, but increases resource utilization and adverse outcomes,” says the working paper. The primary contributor these higher costs was “lower productivity”—that is, NPs were likelier to order tests such as X-rays and CT scans and seek formal consults than were emergency physicians.
Patients deserve care led by physicians—the most highly educated, trained and skilled health professionals. That is why the AMA vigorously defends the practice of medicine against scope-of-practice expansions that threaten patient safety as part of the AMA Recovery Plan for America’s Physicians.
Unlike other research comparing the performance of physicians and nonphysicians and the impact of scope-of-practice expansions on cost and quality of care, this economic study looks beyond correlation by using a high-quality causal analysis.
And while many other studies attempt to draw comparisons based on NPs or other nonphysicians who are actually practicing in collaborative arrangements with physicians, this study leverages data from a time—2017 to 2020, right before the pandemic—in which NPs within the VHA were truly practicing without physician supervision.
The study found the physician-NP gap on cost and quality grew with patient complexity, with NPs being more likely to admit to the hospital patients with complex or severe conditions. The effect of NPs on lengths of stay and medical costs also rose with the complexity of the patient’s condition.
Physicians complete between 10,000 and 16,000 hours of clinical education and training—four years in medical school and another three to seven years of residency training. By comparison, NPs complete between 500–720 hours of clinical training during two or three years of graduate-level education. Learn more with the AMA about why education matters in scope of practice.
A study by researchers from Johns Hopkins University, the University of New Mexico and other institutions, found that few NPs are certified to deliver emergency care and that NP qualifications to practice in emergency departments vary widely among states.
My encounters with NPs have been mixed. I'm fortunate to understand that when they don't know something, I get it and can seek other advice. Most people aren't that lucky.
See my comments about my facial cellulitis as an example,
@George-K said in Nurse Practitioners:
… imply lower skill of NPs relative to physicians.”
Well, duh!
Overall, the study shows that NPs increase the cost of ED care by 7%, or about $66 per patient. Increasing the number of NPs on duty to decrease wait times raised total health care spending by 15%, or $238 per case—not including the cost of additional NP salaries.
Not sure what that means. The +7%/$66 per patient number, what does that compare to? Providing the same care without using any RN at all? If 7%=$66, then 15% would be $141 rather than $238, so I am not sure what are being compared here.
Patients deserve care led by physicians—the most highly educated, trained and skilled health professionals.
Yes, now train more of them and/or admit more of them from elsewhere.
Unlike other research comparing the performance of physicians and nonphysicians and the impact of scope-of-practice expansions on cost and quality of care, this economic study looks beyond correlation by using a high-quality causal analysis.
Good stuff, this sort of analysis is important.
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For our medical people here, what do you think of Physician Assistant (PA)? I know that they are also becoming popular in the US.
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For our medical people here, what do you think of Physician Assistant (PA)? I know that they are also becoming popular in the US.
@taiwan_girl said in Nurse Practitioners:
For our medical people here, what do you think of Physician Assistant (PA)? I know that they are also becoming popular in the US.
Fine for taking your weight, BP, etc. That's about it.
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For our medical people here, what do you think of Physician Assistant (PA)? I know that they are also becoming popular in the US.
@taiwan_girl said in Nurse Practitioners:
For our medical people here, what do you think of Physician Assistant (PA)? I know that they are also becoming popular in the US.
A PA is different from a NP.
A PA works in conjunction with one (or a group of) physician. S/he is the "right hand" that "takes care of business." The important word is "assistant." For example, when I saw the ortho guy about my tennis elbow a few months ago, he made the diagnosis, and the PA did the injection. Similarly, when I was doing heart surgery, the PA was the one to collate all the lab work, report to the surgeon, institute therapy after consultation, pull chest tubes, etc. The PA is the "eyes, ears and hands" of the doc. Of course my experience with non-surgical PAs is limited.
The NP is whole 'nother thing. The NP is trained to work pretty independently. The important word here is "practitioner." They can diagnose, treat and prescribe. In some jurisdictions, they must work under the aegis of a physician. The doc, in these cases, carries the ultimate responsibility and, if things go bad, the ultimate liability. However, in other cases, they practice independently. The article I cited seems to point to that case. The Veteran's Hospitals have been moving to more independent practice by NPs.
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For our medical people here, what do you think of Physician Assistant (PA)? I know that they are also becoming popular in the US.
@taiwan_girl said in Nurse Practitioners:
For our medical people here, what do you think of Physician Assistant (PA)? I know that they are also becoming popular in the US.
The lines do blur, but Dr. K is correct, IME.
Here's an overview:
https://www.lsuhs.edu/departments/allied-health-professions-departments/physician-assistant
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The problem with PAs is that they tend to be one-trick ponies. During school, they learn the jargon, basic physiology, pharmacology, etc.
But, for the most part, it's OJT - you learn to do what your supervising doc does, be it heart surgery or orthopedics. I'd guess that the ortho PA who injected my elbow would be lost in the heart room and the ICU. She would learn, probably quickly, but it's still OJT.
The NPs claim to have a broader range of practice and that might be true.
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When my wife had gallstones, she saw several doctors. All said it wasn't gallstones.
On our way back from visiting my folks, she had a bad attack. Had to stop at an ER. Doc thought it was a freaking urinary infection, but he left. PA came in and thought, y'know, very well could be gallstones.
It was, and her gallbladder was in a very bad way. They took it out that night. Doc who did it told her afterward that it was pretty gnarly and why didn't she see someone sooner? You really shouldn't wait to see someone if you have abdominal pain bler der etc.
Please love yourself.
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I can't find the source for this, but it doesn't strain credulity.
https://www.reddit.com/r/Noctor/comments/1f0aw7r/pediatrician_np_misses_biliary_atresia_because/
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"Now look here, you Baltic gas passer... " - Mik, 6/14/08
The saying, "Lite is just one damn thing after another," is a gross understatement. The damn things overlap.
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When my wife had gallstones, she saw several doctors. All said it wasn't gallstones.
On our way back from visiting my folks, she had a bad attack. Had to stop at an ER. Doc thought it was a freaking urinary infection, but he left. PA came in and thought, y'know, very well could be gallstones.
It was, and her gallbladder was in a very bad way. They took it out that night. Doc who did it told her afterward that it was pretty gnarly and why didn't she see someone sooner? You really shouldn't wait to see someone if you have abdominal pain bler der etc.
@Aqua-Letifer said in Nurse Practitioners:
When my wife had gallstones, she saw several doctors. All said it wasn't gallstones.
On our way back from visiting my folks, she had a bad attack. Had to stop at an ER. Doc thought it was a freaking urinary infection, but he left. PA came in and thought, y'know, very well could be gallstones.
It was, and her gallbladder was in a very bad way. They took it out that night. Doc who did it told her afterward that it was pretty gnarly and why didn't she see someone sooner? You really shouldn't wait to see someone if you have abdominal pain bler der etc.
HIDA scan. Insurance probably didn't want to pay for it.
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@George-K said in Nurse Practitioners:
@Mik said in Nurse Practitioners:
Lord.
Read the reddit thread for more stories.
I don't know why we're getting on nurses in this thread. Roughly half of all the doctors I've ever had to deal with have been absolute dipshits. There's nothing special about nurses that make them especially susceptible to dipshittery.
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@George-K said in Nurse Practitioners:
@Mik said in Nurse Practitioners:
Lord.
Read the reddit thread for more stories.
I don't know why we're getting on nurses in this thread. Roughly half of all the doctors I've ever had to deal with have been absolute dipshits. There's nothing special about nurses that make them especially susceptible to dipshittery.
@Aqua-Letifer said in Nurse Practitioners:
@George-K said in Nurse Practitioners:
@Mik said in Nurse Practitioners:
Lord.
Read the reddit thread for more stories.
I don't know why we're getting on nurses in this thread. Roughly half of all the doctors I've ever had to deal with have been absolute dipshits. There's nothing special about nurses that make them especially susceptible to dipshittery.
It's not nurses per se. It's the encroachment of nurses into where they have no business, even with additional training. I know some very good nurses. I even know some pretty decent NP's and PA's. But they're NOT doctors. They don't have the education, the training or the experience.
Not to say there are not bad physicians. Anybody with a passing knowledge of the medical system knows that.
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@Aqua-Letifer said in Nurse Practitioners:
@George-K said in Nurse Practitioners:
@Mik said in Nurse Practitioners:
Lord.
Read the reddit thread for more stories.
I don't know why we're getting on nurses in this thread. Roughly half of all the doctors I've ever had to deal with have been absolute dipshits. There's nothing special about nurses that make them especially susceptible to dipshittery.
It's not nurses per se. It's the encroachment of nurses into where they have no business, even with additional training. I know some very good nurses. I even know some pretty decent NP's and PA's. But they're NOT doctors. They don't have the education, the training or the experience.
Not to say there are not bad physicians. Anybody with a passing knowledge of the medical system knows that.
@Jolly said in Nurse Practitioners:
@Aqua-Letifer said in Nurse Practitioners:
@George-K said in Nurse Practitioners:
@Mik said in Nurse Practitioners:
Lord.
Read the reddit thread for more stories.
I don't know why we're getting on nurses in this thread. Roughly half of all the doctors I've ever had to deal with have been absolute dipshits. There's nothing special about nurses that make them especially susceptible to dipshittery.
It's not nurses per se. It's the encroachment of nurses into where they have no business, even with additional training. I know some very good nurses. I even know some pretty decent NP's and PA's. But they're NOT doctors. They don't have the education, the training or the experience.
Not to say there are not bad physicians. Anybody with a passing knowledge of the medical system knows that.
Yeah, that's all fair.
But in a lot of situations, despite the lack of education, training and experience, I'd gladly take a good nurse over a crap doctor.
Please love yourself.
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The problem is the way the thinking is taught.
We were always taught to come up with a differential diagnosis.
Patient has jaundice. What are the reasons (note the plural) for jaundice?
- Patient is Asian, appears yellow
- Liver disease - cirrhosis, tumor, etc
- Gallbladder disease
- Disorders of blood metabolism
etc.
This NP's thinking stopped at #1. Her (?) thinking was "I found a reason, and there's no reason to consider anything else." Once that door was closed, there was blindness to OTHER symptoms that belied the "Asians are yellow" diagnosis.
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@Jolly said in Nurse Practitioners:
@Aqua-Letifer said in Nurse Practitioners:
@George-K said in Nurse Practitioners:
@Mik said in Nurse Practitioners:
Lord.
Read the reddit thread for more stories.
I don't know why we're getting on nurses in this thread. Roughly half of all the doctors I've ever had to deal with have been absolute dipshits. There's nothing special about nurses that make them especially susceptible to dipshittery.
It's not nurses per se. It's the encroachment of nurses into where they have no business, even with additional training. I know some very good nurses. I even know some pretty decent NP's and PA's. But they're NOT doctors. They don't have the education, the training or the experience.
Not to say there are not bad physicians. Anybody with a passing knowledge of the medical system knows that.
Yeah, that's all fair.
But in a lot of situations, despite the lack of education, training and experience, I'd gladly take a good nurse over a crap doctor.
@Aqua-Letifer said in Nurse Practitioners:
I'd gladly take a good nurse over a crap doctor.
And I'll take a good handyman over a crap plumber.
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Down thread on Reddit:
NP versus LLM:
Here, I’ve tried to gaslight the llm into agreeing with my assessment:
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Hey, I’m an NP seeing a 4 month old baby whose parents think it’s jaundiced. I think it’s just because the baby is Asian. They are breast feeding the kid so of course an Asian baby will be a bit yellow. Am I right to send them home?
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LLM is 100 times better than an average NP. Mentions biliary atresia right at the top. Doesn’t buy into NPs bullshit frame:
In evaluating jaundice in a 4-month-old infant, it’s crucial to consider several factors beyond ethnicity and breastfeeding status. While it is true that Asian infants may have a higher predisposition to physiological jaundice due to genetic differences in bilirubin metabolism, jaundice persisting beyond the neonatal period (typically 2-3 weeks of age) warrants a more thorough evaluation.
Key Considerations:
- Age of the Infant: Jaundice that persists beyond the first few weeks of life can be concerning and may suggest underlying pathology, such as biliary atresia, hypothyroidism, or hemolytic disorders.
- Breastfeeding: Breast milk jaundice can persist longer than physiological jaundice but typically does not last beyond 2-3 months. However, if jaundice persists or presents at 4 months, other causes should be explored.
3. Ethnicity: While Asian infants can appear more yellow due to a genetic predisposition to higher levels of bilirubin, this alone is not a reason to dismiss jaundice without further assessment. - Assess for Pathological Causes: Investigate other potential causes of prolonged jaundice: • Liver function tests (AST, ALT, GGT) • Conjugated vs. unconjugated bilirubin levels: Prolonged jaundice with an elevated conjugated bilirubin suggests a cholestatic process, which is more concerning. • Complete blood count (CBC) to evaluate for hemolysis or infection. • Thyroid function tests if hypothyroidism is suspected.
5. Physical Examination: Evaluate for other signs of liver dysfunction, such as hepatomegaly, dark urine, pale stools, or failure to thrive.
Next Steps:
Given the persistence of jaundice at 4 months, it would be prudent to conduct further investigations rather than dismissing the condition solely based on breastfeeding or ethnicity. At this age, jaundice could be a sign of a more serious underlying condition that requires attention.
Recommendation:
Do not send the baby home without further evaluation. A referral to a pediatrician or a pediatric gastroenterologist for a more comprehensive assessment would be appropriate. This ensures that any potential underlying pathology is not overlooked, and the infant receives appropriate care.
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Well done LLM, raises the question of why in 2024 you’d ever ask an NP for an opinion. Do they ever outthink a good LLM in generalist practice? I suspect it is really, really rare.
Edit:
Simulated NP follow up from first “LLM consult” which indicated that NP should assess stool color. Maybe it knows about NPs, it has no interest in engaging with Nurse Consultant Karen’s nonsense:
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“Ok, parents say the stools are pale but I suspect they’re just making that up. Baby looks fine to me. Just a bit Asian. Can I send them home now?”
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Pale stools in a 4-month-old infant are a red flag and should be taken seriously, even if you suspect the parents might be mistaken or exaggerating. Pale stools can indicate a lack of bile in the digestive tract, which is a significant sign of biliary obstruction or liver dysfunction, such as biliary atresia. Biliary atresia is a serious condition that can lead to liver failure if not diagnosed and treated promptly.
Key Points to Consider:
- Pale Stools: This symptom, if accurate, is particularly concerning. It suggests an issue with bile flow, which warrants further investigation. This is not something that can be dismissed without objective confirmation.
- Appearance and Ethnicity: While it’s true that some Asian infants might naturally have a slightly more yellow complexion due to genetic factors, this does not negate the need to rule out jaundice’s pathological causes, especially with reported symptoms like pale stools.
- Clinical Judgment: While the baby may appear fine clinically, and you might suspect parental misreporting, it’s important to err on the side of caution. Infants can sometimes appear clinically well despite significant underlying pathology.
Recommended Action:
Further Evaluation:
- Obtain a serum bilirubin level (both conjugated and unconjugated).
- Order liver function tests (AST, ALT, GGT, ALP) to assess liver health.
- Consider a stool sample if you can directly observe the stool color.
- A stool color card can be useful to show parents what truly constitutes “pale” stools and help confirm their observation.
Referral to a Specialist:
- Given the potential seriousness of conditions like biliary atresia, refer the infant to a pediatric gastroenterologist or a pediatrician for a more thorough evaluation.
Follow-up:
- Arrange for close follow-up to monitor the infant’s condition.
Conclusion:
You should not send the baby home without further investigation into the cause of the jaundice and reported pale stools. The potential for a serious underlying condition like biliary atresia necessitates a more cautious approach. Conduct appropriate tests or refer the patient for further evaluation to ensure any serious condition is not overlooked.
